Basic Information
| Provider Information | |||||||||
| NPI: | 1164694485 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LLOYD M.WOLF III D.O. INTERNAL MEDICINE, PC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 2 MERIDIAN BLVD | ||||||||
| Address2: | |||||||||
| City: | WYOMISSING | ||||||||
| State: | PA | ||||||||
| PostalCode: | 196103202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6107433139 | ||||||||
| FaxNumber: | 6107433143 | ||||||||
| Practice Location | |||||||||
| Address1: | 2 MERIDIAN BLVD | ||||||||
| Address2: | |||||||||
| City: | WYOMISSING | ||||||||
| State: | PA | ||||||||
| PostalCode: | 196103202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6107433139 | ||||||||
| FaxNumber: | 6107433143 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/26/2008 | ||||||||
| LastUpdateDate: | 03/11/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WOLF | ||||||||
| AuthorizedOfficialFirstName: | LLOYD | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6107433139 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | III | ||||||||
| AuthorizedOfficialCredential: | DO | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | OS012325 | PA | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
No ID Information.