Healthcare Provider Details

I. General information

NPI: 1710909825
Provider Name (Legal Business Name): STEPHEN M WOLK MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 12/17/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

943 N CHURCH ST
HAZLETON PA
18201-1839
US

IV. Provider business mailing address

943 N CHURCH ST
HAZLETON PA
18201-1839
US

V. Phone/Fax

Practice location:
  • Phone: 570-455-4428
  • Fax: 570-455-6277
Mailing address:
  • Phone: 570-455-4428
  • Fax: 570-455-6277

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: STEPHEN M WOLK
Title or Position: MD
Credential: MD
Phone: 570-455-4428