Provider Demographics
NPI:1508220062
Name:WOLF, MARLISA ROSE (MD)
Entity Type:Individual
Prefix:DR
First Name:MARLISA
Middle Name:ROSE
Last Name:WOLF
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MISS
Other - First Name:MARLISA
Other - Middle Name:ROSE
Other - Last Name:HAWLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:UNIVERSITY PEDIATRICIANS
Mailing Address - Street 2:4201 ST. ANTOINE UHC 5D - 226
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201-2119
Mailing Address - Country:US
Mailing Address - Phone:313-966-5051
Mailing Address - Fax:313-966-0665
Practice Address - Street 1:CHILDREN'S HOSPITAL OF MI - 3RD FL
Practice Address - Street 2:3901 BEAUBIEN
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201
Practice Address - Country:US
Practice Address - Phone:313-966-0128
Practice Address - Fax:313-993-0390
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-11
Last Update Date:2019-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MI4301116977208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty