Basic Information
| Provider Information | |||||||||
| NPI: | 1326039488 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WOLF EYE ASSOCIATES, PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 249 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | LEWISTON | ||||||||
| State: | ME | ||||||||
| PostalCode: | 042407053 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2077839653 | ||||||||
| FaxNumber: | 2077864362 | ||||||||
| Practice Location | |||||||||
| Address1: | 249 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | LEWISTON | ||||||||
| State: | ME | ||||||||
| PostalCode: | 042407053 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2077839653 | ||||||||
| FaxNumber: | 2077864362 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/28/2005 | ||||||||
| LastUpdateDate: | 08/03/2009 | ||||||||
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| AuthorizedOfficialLastName: | WOLF | ||||||||
| AuthorizedOfficialFirstName: | KENNETH | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | OPHTHALMOLOGIST/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2077839653 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 30008301 | 01 | NH | NEW HAMPSHIRE MEDICAID | OTHER | 112040000 | 05 | ME | MEDICAID |