Provider Demographics
NPI: | 1710995121 |
---|---|
Name: | WOLF, BERNARD G II (DO) |
Entity Type: | Individual |
Prefix: | MR |
First Name: | BERNARD |
Middle Name: | G |
Last Name: | WOLF |
Suffix: | II |
Gender: | M |
Credentials: | DO |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 1315 N HIGHLAND AVE |
Mailing Address - Street 2: | SUITE 100 |
Mailing Address - City: | AURORA |
Mailing Address - State: | IL |
Mailing Address - Zip Code: | 60506-1400 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 630-896-6565 |
Mailing Address - Fax: | 630-896-9735 |
Practice Address - Street 1: | 1315 N HIGHLAND AVE |
Practice Address - Street 2: | SUITE 100 |
Practice Address - City: | AURORA |
Practice Address - State: | IL |
Practice Address - Zip Code: | 60506-1400 |
Practice Address - Country: | US |
Practice Address - Phone: | 630-896-6565 |
Practice Address - Fax: | 630-896-9735 |
Is Sole Proprietor?: | Yes |
Enumeration Date: | 2006-08-03 |
Last Update Date: | 2024-02-29 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
IL | 36030570 | 207R00000X |
IL | 036050670 | 2084N0400X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine | |
No | 2084N0400X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
D14282 | Medicare UPIN | ||
646311 | Medicare ID - Type Unspecified |