MEDICARE: RYAN MICHAEL WOLF 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	208000000X	Pediatrics Physician	60998	TN
2	390200000X	Student in an Organized Health Care Education/Training Program
3	208000000X	Pediatrics Physician	2023-00579	NC

General Provider Information

NPI Number	:	1992237515
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RYAN MICHAEL WOLF M.D.

Provider Business Mailing Address
First Line	:	100 KIMEL FOREST DR
Second Line	:
City	:	WINSTON SALEM
State	:	NC
Zip	:	27103-6074
Country	:	US
Telephone Number	:	336-716-0238
Fax Number	:

Provider Business Practice Location Address
First Line	:	MEDICAL CENTER BLVD
Second Line	:
City	:	WINSTON SALEM
State	:	NC
Zip	:	27157-9760
Country	:	US
Telephone Number	:	336-716-9252
Fax Number	:	336-713-9387

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

Provider Enumeration Date	:	04/02/2017
Last Update Date	:	07/14/2023

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