Provider Demographics
NPI:1972804110
Name:WOLFCHASE FAMILY MEDICAL CARE, PLLC
Entity Type:Organization
Organization Name:WOLFCHASE FAMILY MEDICAL CARE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:R
Authorized Official - Last Name:WICKMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD, MPH
Authorized Official - Phone:901-377-3001
Mailing Address - Street 1:8485 US HIGHWAY 64 STE 101
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38133-4102
Mailing Address - Country:US
Mailing Address - Phone:901-377-3001
Mailing Address - Fax:901-377-3130
Practice Address - Street 1:8485 US HIGHWAY 64 STE 101
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38133-4102
Practice Address - Country:US
Practice Address - Phone:901-377-3001
Practice Address - Fax:901-377-3130
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-04
Last Update Date:2010-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN22064261QP2300X
TN12858261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care