Healthcare Provider Details

I. General information

NPI: 1285730267
Provider Name (Legal Business Name): SUSAN IRENE WOLF M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SUSAN IRENE WOLF-FELDESMAN M.D.

II. Dates (important events)

Enumeration Date: 09/16/2006
Last Update Date: 10/31/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10180 SE SUNNYSIDE RD KAISER SUNNYSIDE MEDICAL OFFICE
CLACKAMAS OR
97015-8970
US

IV. Provider business mailing address

10180 SE SUNNYSIDE RD KAISER SUNNYSIDE MEDICAL OFFICE
CLACKAMAS OR
97015-8970
US

V. Phone/Fax

Practice location:
  • Phone: 503-652-2880
  • Fax:
Mailing address:
  • Phone: 503-652-2880
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License NumberMD16528
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License NumberMD00034377
License Number StateWA
# 3
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberMD16528
License Number StateOR
# 4
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberMD00034377
License Number StateWA
# 5
Primary TaxonomyN
Taxonomy Code2085U0001X
TaxonomyDiagnostic Ultrasound Physician
License NumberMD16528
License Number StateOR
# 6
Primary TaxonomyN
Taxonomy Code2085U0001X
TaxonomyDiagnostic Ultrasound Physician
License NumberMD00034377
License Number StateWA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: