MEDICARE: MR. ERIC D WOLF PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	385-001382	IL

General Provider Information

NPI Number	:	1023106093
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ERIC D WOLF PA

Provider Business Mailing Address
First Line	:	2010 JACOBSSEN DR
Second Line	:
City	:	NORMAL
State	:	IL
Zip	:	61761-6280
Country	:	US
Telephone Number	:	309-452-0995
Fax Number	:	217-718-5284

Provider Business Practice Location Address
First Line	:	2151 W WHITE OAKS DR
Second Line	:
City	:	SPRINGFIELD
State	:	IL
Zip	:	62704-6410
Country	:	US
Telephone Number	:	217-717-4404
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/11/2006
Last Update Date	:	08/28/2023

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