Provider Demographics
NPI:1376546754
Name:WOLF CREEK MEDICAL ASSOCIATES
Entity Type:Organization
Organization Name:WOLF CREEK MEDICAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JEANNE
Authorized Official - Middle Name:L
Authorized Official - Last Name:BLAKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:724-450-7004
Mailing Address - Street 1:647 N BROAD STREET EXT
Mailing Address - Street 2:WOLF CREEK MEDICAL ASSOCIATES
Mailing Address - City:GROVE CITY
Mailing Address - State:PA
Mailing Address - Zip Code:16127-4604
Mailing Address - Country:US
Mailing Address - Phone:724-450-7004
Mailing Address - Fax:724-450-7013
Practice Address - Street 1:647 N BROAD STREET EXT
Practice Address - Street 2:WOLF CREEK MEDICAL ASSOCIATES
Practice Address - City:GROVE CITY
Practice Address - State:PA
Practice Address - Zip Code:16127-4604
Practice Address - Country:US
Practice Address - Phone:724-450-7004
Practice Address - Fax:724-450-7013
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-31
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X, 207X00000X, 367500000X
PA207V00000X, 208000000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001960970Medicaid
72326Medicare PIN