Healthcare Provider Details

I. General information

NPI: 1134120934
Provider Name (Legal Business Name): BRUCE ALEXANDER WOLF MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2005
Last Update Date: 10/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

906 WOODLAND DR SUITE 102
ELIZABETHTOWN KY
42701-2752
US

IV. Provider business mailing address

906 WOODLAND DR SUITE 102
ELIZABETHTOWN KY
42701-2752
US

V. Phone/Fax

Practice location:
  • Phone: 270-765-5127
  • Fax: 270-765-2653
Mailing address:
  • Phone: 270-765-5127
  • Fax: 270-765-2653

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number21707
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number21707
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: