Healthcare Provider Details

I. General information

NPI: 1437231321
Provider Name (Legal Business Name): BLAISE JOSEPH WOLFRUM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2006
Last Update Date: 08/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1375 E SCHAUMBURG RD SUITE 260
SCHAUMBURG IL
60194-5166
US

IV. Provider business mailing address

1375 E SCHAUMBURG RD SUITE 260
SCHAUMBURG IL
60194-5166
US

V. Phone/Fax

Practice location:
  • Phone: 847-895-4540
  • Fax: 847-895-4544
Mailing address:
  • Phone: 847-895-4540
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number036079918
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code2084P0802X
TaxonomyAddiction Psychiatry Physician
License Number036079918
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: