Provider Demographics
NPI:1366486821
Name:WOLF, BRADLEY A (MD)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:A
Last Name:WOLF
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:PO BOX 405827
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-5800
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6029 WALNUT GROVE RD
Practice Address - Street 2:SUITE 401
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38120-2112
Practice Address - Country:US
Practice Address - Phone:901-226-0456
Practice Address - Fax:901-226-0458
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2019-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS15329208G00000X
ARE-5843208G00000X
TN26581208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3713059Medicaid
AR8P057OtherBCBS GRP
AR97632OtherBCBS INDIVID
TN3810777Medicaid
TN4033006OtherBCBS
MS00118754Medicaid
TNG49394OtherUPIN #
MS09016196Medicaid
AR131894001Medicaid
TN4033006OtherBCBS
MO203912118Medicaid