Provider Demographics
NPI:1679619449
Name:PAINT CREEK OBSTETRICS & GYNECOLOGY PC
Entity Type:Organization
Organization Name:PAINT CREEK OBSTETRICS & GYNECOLOGY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:PHILLIP
Authorized Official - Last Name:WOLFE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-650-1534
Mailing Address - Street 1:6700 NORTH ROCHESTER ROAD
Mailing Address - Street 2:STE 112
Mailing Address - City:ROCHESTER HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48306
Mailing Address - Country:US
Mailing Address - Phone:248-650-1534
Mailing Address - Fax:248-650-1537
Practice Address - Street 1:6700 NORTH ROCHESTER ROAD
Practice Address - Street 2:STE 112
Practice Address - City:ROCHESTER HILLS
Practice Address - State:MI
Practice Address - Zip Code:48306
Practice Address - Country:US
Practice Address - Phone:248-650-1534
Practice Address - Fax:248-650-1537
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MITWO53571207V00000X
MICCO52610207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3133379Medicaid
MI3382641Medicaid
F27398Medicare UPIN
MIN79530002Medicare ID - Type UnspecifiedDR C
MIN79530001Medicare ID - Type UnspecifiedDR W
MI3133379Medicaid