Basic Information
| Provider Information | |||||||||
| NPI: | 1508220062 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WOLF | ||||||||
| FirstName: | MARLISA | ||||||||
| MiddleName: | ROSE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HAWLEY | ||||||||
| OtherFirstName: | MARLISA | ||||||||
| OtherMiddleName: | ROSE | ||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | UNIVERSITY PEDIATRICIANS | ||||||||
| Address2: | 4201 ST. ANTOINE UHC 5D - 226 | ||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482012119 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3139665051 | ||||||||
| FaxNumber: | 3139660665 | ||||||||
| Practice Location | |||||||||
| Address1: | CHILDREN'S HOSPITAL OF MI - 3RD FL | ||||||||
| Address2: | 3901 BEAUBIEN | ||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3139660128 | ||||||||
| FaxNumber: | 3139930390 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2016 | ||||||||
| LastUpdateDate: | 04/17/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 208000000X | 4301116977 | MI | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.