Provider Demographics
NPI:1437231321
Name:WOLFRUM, BLAISE JOSEPH (MD)
Entity Type:Individual
Prefix:DR
First Name:BLAISE
Middle Name:JOSEPH
Last Name:WOLFRUM
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 1:1375 E SCHAUMBURG RD
Mailing Address - Street 2:SUITE 260
Mailing Address - City:SCHAUMBURG
Mailing Address - State:IL
Mailing Address - Zip Code:60194-5166
Mailing Address - Country:US
Mailing Address - Phone:847-895-4540
Mailing Address - Fax:
Practice Address - Street 1:1375 E SCHAUMBURG RD
Practice Address - Street 2:SUITE 260
Practice Address - City:SCHAUMBURG
Practice Address - State:IL
Practice Address - Zip Code:60194-5166
Practice Address - Country:US
Practice Address - Phone:847-895-4540
Practice Address - Fax:847-895-4544
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2015-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360799182084P0800X, 2084P0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0802XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036079918Medicaid
E46403Medicare UPIN
IL036079918Medicaid