Healthcare Provider Details

I. General information

NPI: 1245463595
Provider Name (Legal Business Name): KEITH JEREMY WOLFE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/02/2009
Last Update Date: 11/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3740 N HALSTED ST APT 310
CHICAGO IL
60613-5653
US

IV. Provider business mailing address

3740 N HALSTED ST APT 310
CHICAGO IL
60613-5653
US

V. Phone/Fax

Practice location:
  • Phone: 937-367-4712
  • Fax:
Mailing address:
  • Phone: 937-367-4712
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number35.099508
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number036130944
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: