Provider Demographics
NPI:1164489647
Name:WOOLF, MERVYN (MD)
Entity Type:Individual
Prefix:
First Name:MERVYN
Middle Name:
Last Name:WOOLF
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:245 CHAPMAN STREET
Mailing Address - Street 2:SUITE 105
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02905-4507
Mailing Address - Country:US
Mailing Address - Phone:401-490-0916
Mailing Address - Fax:401-490-0979
Practice Address - Street 1:363 HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:FALL RIVER
Practice Address - State:MA
Practice Address - Zip Code:02720-3703
Practice Address - Country:US
Practice Address - Phone:508-679-3131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2019-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI9707207L00000X
RIMD09707207L00000X
MA78465207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIMW05302Medicaid
RIMW05302Medicaid
RI007010178Medicare ID - Type UnspecifiedPROVIDER NUMBER