Provider Demographics
NPI:1649368663
Name:JAY M. WOLKOV DO PC
Entity type:Organization
Organization Name:JAY M. WOLKOV DO PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BILLING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:LOUISE
Authorized Official - Middle Name:E
Authorized Official - Last Name:ANDERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-641-1399
Mailing Address - Street 1:707 N IOWA ST
Mailing Address - Street 2:
Mailing Address - City:GUNNISON
Mailing Address - State:CO
Mailing Address - Zip Code:81230-2229
Mailing Address - Country:US
Mailing Address - Phone:970-641-1771
Mailing Address - Fax:970-641-9017
Practice Address - Street 1:707 N IOWA ST
Practice Address - Street 2:
Practice Address - City:GUNNISON
Practice Address - State:CO
Practice Address - Zip Code:81230-2229
Practice Address - Country:US
Practice Address - Phone:970-641-1771
Practice Address - Fax:970-641-9017
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-11
Last Update Date:2011-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO04808093Medicaid
COCD7108Medicare PIN