Provider Demographics
NPI:1710909825
Name:STEPHEN M WOLK MD PC
Entity Type:Organization
Organization Name:STEPHEN M WOLK MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:M
Authorized Official - Last Name:WOLK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:570-455-4428
Mailing Address - Street 1:943 N CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:HAZLETON
Mailing Address - State:PA
Mailing Address - Zip Code:18201-1839
Mailing Address - Country:US
Mailing Address - Phone:570-455-4428
Mailing Address - Fax:570-455-6277
Practice Address - Street 1:943 N CHURCH ST
Practice Address - Street 2:
Practice Address - City:HAZLETON
Practice Address - State:PA
Practice Address - Zip Code:18201-1839
Practice Address - Country:US
Practice Address - Phone:570-455-4428
Practice Address - Fax:570-455-6277
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-25
Last Update Date:2009-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD038358L207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0009196560001Medicaid
PAC34068Medicare UPIN
PA0009196560001Medicaid