Provider Demographics
NPI: | 1710987870 |
---|---|
Name: | WOLFE, JOEL R (MD) |
Entity Type: | Individual |
Prefix: | DR |
First Name: | JOEL |
Middle Name: | R |
Last Name: | WOLFE |
Suffix: | |
Gender: | M |
Credentials: | MD |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 370 120TH AVE |
Mailing Address - Street 2: | |
Mailing Address - City: | HOLLAND |
Mailing Address - State: | MI |
Mailing Address - Zip Code: | 49424-2196 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 616-396-5855 |
Mailing Address - Fax: | 616-396-5720 |
Practice Address - Street 1: | 370 120TH AVE |
Practice Address - Street 2: | |
Practice Address - City: | HOLLAND |
Practice Address - State: | MI |
Practice Address - Zip Code: | 49424-2196 |
Practice Address - Country: | US |
Practice Address - Phone: | 616-396-5855 |
Practice Address - Fax: | 616-396-5720 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2005-07-29 |
Last Update Date: | 2014-03-05 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
MI | JW051928 | 207X00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207X00000X | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
MI | 2977390 | Medicaid | |
MI | JW051928 | Other | STATE LICENSE |
MI | 0888470001 | Other | MEDICARE DME PTAN |
MI | 4361552 | Other | AETNA |
MI | P70442 | Other | BLUE CARE NETWORK |
MI | F23757 | Medicare UPIN | |
MI | P70442 | Other | BLUE CARE NETWORK |