MEDICARE: MR. BRUCE CARLISLE WOLF MSPT

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	208100000X	Physical Medicine & Rehabilitation Physician	PT2246	AR

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	650019382	OTHER	AR	PALMETTO GBA RR MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1619938511
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. BRUCE CARLISLE WOLF MSPT

Provider Business Mailing Address
First Line	:	603 NORTHTOWN
Second Line	:
City	:	MOUNTAIN HOME
State	:	AR
Zip	:	72653-3121
Country	:	US
Telephone Number	:	870-425-5180
Fax Number	:	870-425-5185

Provider Business Practice Location Address
First Line	:	603 NORTHTOWN
Second Line	:
City	:	MOUNTAIN HOME
State	:	AR
Zip	:	72653-3121
Country	:	US
Telephone Number	:	870-425-5180
Fax Number	:	870-425-5185

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

Provider Enumeration Date	:	03/30/2006
Last Update Date	:	11/17/2009

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