Basic Information
Provider Information
NPI: 1003805904
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: WOLF
FirstName: ROBERT
MiddleName: J
NamePrefix: DR.
NameSuffix:  
Credential: MD
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 53 HUNTER RD
Address2:  
City: UXBRIDGE
State: MA
PostalCode: 015691153
CountryCode: US
TelephoneNumber: 5087790357
FaxNumber:  
Practice Location
Address1: 1540 LAKE LANSING RD
Address2: SUITE 107
City: LANSING
State: MI
PostalCode: 489123756
CountryCode: US
TelephoneNumber: 5179133800
FaxNumber: 5179133901
Other Information
ProviderEnumerationDate: 10/14/2005
LastUpdateDate: 10/08/2009
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
2085R0202X4301073351MIY Allopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology

ID Information
IDTypeStateIssuerDescription
102334901MIMCLAREN HEALTH PLAN-COMMERCIALOTHER
20000000105201MIPHP FAMILYCAREOTHER
0M2144005101MIMEDICARE ADVANTAGEOTHER
102334901MIMCLAREN HEALTH PLAN-MEDICAIDOTHER
772102401 AETNAOTHER
P0035080901 RAILROAD MEDICAREOTHER
20000000105201MIPHPOTHER
102334901MIMCLAREN HEALTH ADVANTAGEOTHER
25518901 PHCSOTHER
481584705MI MEDICAID
300331435101MIBLUE CROSS BLUE SHIELD OF MICHIGAN/BLUE CARE NETWORKOTHER


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