Provider Demographics
NPI:1619938511
Name:WOLF, BRUCE CARLISLE (MSPT)
Entity Type:Individual
Prefix:MR
First Name:BRUCE
Middle Name:CARLISLE
Last Name:WOLF
Suffix:
Gender:M
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:603 NORTHTOWN
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:AR
Mailing Address - Zip Code:72653-3121
Mailing Address - Country:US
Mailing Address - Phone:870-425-5180
Mailing Address - Fax:870-425-5185
Practice Address - Street 1:603 NORTHTOWN
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME
Practice Address - State:AR
Practice Address - Zip Code:72653-3121
Practice Address - Country:US
Practice Address - Phone:870-425-5180
Practice Address - Fax:870-425-5185
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-30
Last Update Date:2009-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPT2246208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR143668742Medicaid
AR650019382OtherPALMETTO GBA RR MEDICARE
AR650019382OtherPALMETTO GBA RR MEDICARE
AR5U255Medicare ID - Type Unspecified