MEDICARE: DR. KEITH JEREMY WOLFE M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2085R0202X	Diagnostic Radiology Physician	35.099508	OH
2	2085R0202X	Diagnostic Radiology Physician	036130944	IL

General Provider Information

NPI Number	:	1245463595
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KEITH JEREMY WOLFE M.D.

Provider Business Mailing Address
First Line	:	3740 N HALSTED ST
Second Line	:	APT 310
City	:	CHICAGO
State	:	IL
Zip	:	60613-5653
Country	:	US
Telephone Number	:	937-367-4712
Fax Number	:

Provider Business Practice Location Address
First Line	:	3740 N HALSTED ST
Second Line	:	APT 310
City	:	CHICAGO
State	:	IL
Zip	:	60613-5653
Country	:	US
Telephone Number	:	937-367-4712
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/02/2009
Last Update Date	:	11/07/2014

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