Healthcare Provider Details

I. General information

NPI: 1376546754
Provider Name (Legal Business Name): WOLF CREEK MEDICAL ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/31/2005
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

647 N BROAD STREET EXT WOLF CREEK MEDICAL ASSOCIATES
GROVE CITY PA
16127-4604
US

IV. Provider business mailing address

647 N BROAD STREET EXT WOLF CREEK MEDICAL ASSOCIATES
GROVE CITY PA
16127-4604
US

V. Phone/Fax

Practice location:
  • Phone: 724-450-7004
  • Fax: 724-450-7013
Mailing address:
  • Phone: 724-450-7004
  • Fax: 724-450-7013

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number StatePA
# 5
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number StatePA
# 6
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number StatePA

VIII. Authorized Official

Name: MRS. JEANNE L BLAKE
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 724-450-7004