Provider Demographics
NPI:1629069927
Name:WOLF, MYLES SELIG (MD)
Entity Type:Individual
Prefix:DR
First Name:MYLES
Middle Name:SELIG
Last Name:WOLF
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:680 N. LAKE SHORE DRIVE, SUITE 1000
Mailing Address - Street 2:NORTHWESTERN MEDICAL FACULTY FOUNDATION, INC.
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-4546
Mailing Address - Country:US
Mailing Address - Phone:312-695-9797
Mailing Address - Fax:
Practice Address - Street 1:251 E HURON ST
Practice Address - Street 2:NORTHWESTERN MEMORIAL HOSPITAL - GALTER PAVILION 18-250
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2908
Practice Address - Country:US
Practice Address - Phone:312-695-9797
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-04
Last Update Date:2013-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA157288207R00000X, 207RN0300X
IL036134262207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0172481Medicaid
MAJ24987OtherBCBS MA
MA157288OtherTUFTS HEALTH PLAN
MAJ24987OtherBCBS MA
MA0172481Medicaid