Basic Information
| Provider Information | |||||||||
| NPI: | 1003805904 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WOLF | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| 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 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 4301073351 | MI | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 1023349 | 01 | MI | MCLAREN HEALTH PLAN-COMMERCIAL | OTHER | 0M21440051 | 01 | MI | MEDICARE ADVANTAGE | OTHER | 1023349 | 01 | MI | MCLAREN HEALTH PLAN-MEDICAID | OTHER | 7721024 | 01 | AETNA | OTHER | 4815847 | 05 | MI | MEDICAID | P00350809 | 01 | RAILROAD MEDICARE | OTHER | 1023349 | 01 | MI | MCLAREN HEALTH ADVANTAGE | OTHER | 200000001052 | 01 | MI | PHP | OTHER | 200000001052 | 01 | MI | PHP FAMILYCARE | OTHER | 255189 | 01 | PHCS | OTHER | 3003314351 | 01 | MI | BLUE CROSS BLUE SHIELD OF MICHIGAN/BLUE CARE NETWORK | OTHER |