Healthcare Provider Details

I. General information

NPI: 1316042708
Provider Name (Legal Business Name): BRIAN E WOLF M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2006
Last Update Date: 12/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 SOUTH ST
SOUTHBRIDGE MA
01550-4051
US

IV. Provider business mailing address

100 SOUTH ST
SOUTHBRIDGE MA
01550-4051
US

V. Phone/Fax

Practice location:
  • Phone: 508-765-9771
  • Fax: 508-764-2448
Mailing address:
  • Phone: 508-765-9771
  • Fax: 508-764-2448

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086X0206X
TaxonomySurgical Oncology Physician
License Number56478
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: