Provider Demographics
NPI:1578538443
Name:WOLF, FREDERICK GREGORY (MD)
Entity Type:Individual
Prefix:
First Name:FREDERICK
Middle Name:GREGORY
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 1:6077 PRIMACY PKWY STE 140
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38119-5742
Mailing Address - Country:US
Mailing Address - Phone:901-725-8347
Mailing Address - Fax:901-259-7637
Practice Address - Street 1:1244 PRIMACY PKWY
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119-0201
Practice Address - Country:US
Practice Address - Phone:901-767-8662
Practice Address - Fax:901-767-8666
Is Sole Proprietor?:No
Enumeration Date:2006-02-22
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN36520207X00000X, 207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN7951429OtherAETNA
TN3874732Medicaid
TN00002219069 05OtherUNITED HEALTHCARE
TN36520OtherTN LICENSE
TN0995742OtherCIGNA
TN4179731OtherBCBS
TN620819926OtherCIGNA
TNP00624366OtherRAILROAD MEDICARE
MS07187860Medicaid
TN620819926OtherAETNA
MS07187860Medicaid
TN0723280002Medicare NSC
TN620819926OtherCIGNA
TN3371161Medicaid
TN38747321Medicare PIN
TNH63832Medicare UPIN
TN3371161Medicare PIN