Provider Demographics
NPI:1700873361
Name:WOLSH, LOREN (MD)
Entity Type:Individual
Prefix:
First Name:LOREN
Middle Name:
Last Name:WOLSH
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 1:58 LUSK ST
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:NY
Mailing Address - Zip Code:13790-2541
Mailing Address - Country:US
Mailing Address - Phone:607-763-6293
Mailing Address - Fax:607-763-6717
Practice Address - Street 1:33-57 HARRISON ST
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:NY
Practice Address - Zip Code:13790-2107
Practice Address - Country:US
Practice Address - Phone:607-763-6285
Practice Address - Fax:607-763-6701
Is Sole Proprietor?:No
Enumeration Date:2005-09-29
Last Update Date:2010-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1149181207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01427590Medicaid
C26064Medicare UPIN
NY01427590Medicaid