Healthcare Provider Details

I. General information

NPI: 1285739177
Provider Name (Legal Business Name): RICHARD M WOLF MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2006
Last Update Date: 05/01/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

611 W. PARK ST. UROLOGY
URBANA IL
61801
US

IV. Provider business mailing address

611 W. PARK ST. BWPC
URBANA IL
61801-2500
US

V. Phone/Fax

Practice location:
  • Phone: 217-383-3160
  • Fax: 217-383-4868
Mailing address:
  • Phone: 217-383-6792
  • Fax: 217-383-4868

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number036084231
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: