Provider Demographics
NPI:1578613568
Name:WOLF, BRYAN A (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:A
Last Name:WOLF
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3400 CIVIC CENTER BLVD
Mailing Address - Street 2:ROOM 5135
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104
Mailing Address - Country:US
Mailing Address - Phone:215-590-2266
Mailing Address - Fax:215-590-2171
Practice Address - Street 1:3400 CIVIC CENTER BLVD
Practice Address - Street 2:ROOM 5135
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-4306
Practice Address - Country:US
Practice Address - Phone:215-590-2266
Practice Address - Fax:215-590-2171
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA043053-L174400000X
NJ174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist