Healthcare Provider Details

I. General information

NPI: 1578589354
Provider Name (Legal Business Name): STEPHEN M WOLK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/14/2006
Last Update Date: 08/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 MOISEY DRIVE SUITE 103
HAZLETON PA
18202
US

IV. Provider business mailing address

700 E BROAD ST
HAZLETON PA
18201-6835
US

V. Phone/Fax

Practice location:
  • Phone: 570-501-6580
  • Fax: 570-501-6598
Mailing address:
  • Phone: 570-288-8881
  • Fax: 570-288-8065

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberMD038358L
License Number StatePA

VII. Legacy identifiers

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

# 1
Identifier0009196560001
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: