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General NPI Number Information
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NPI Number | 1245463595
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Entity Type | Individual
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Provider Name | KEITH JEREMY WOLFE M.D.
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Gender | Male
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Dates
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Enumeration Date | 09/02/2009
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Last Update Date | 11/07/2014
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Provider Practice Location Address
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Address Line | 3740 N HALSTED ST APT 310
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City | CHICAGO
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State | IL
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Zip | 60613-5653
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Country | US
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Telephone | 937-367-4712
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Fax |
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Provider Business Mailing Address
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Address Line | 3740 N HALSTED ST APT 310
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City | CHICAGO
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State | IL
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Zip | 60613-5653
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Country | US
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Telephone | 937-367-4712
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2085R0202X
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Taxonomy Name | Diagnostic Radiology Physician
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License Number | 35.099508
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License Number State | OH
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Taxonomy #2
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Taxonomy Code | 2085R0202X
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Taxonomy Name | Diagnostic Radiology Physician
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License Number | 036130944
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License Number State | IL
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