Basic Information
| Provider Information | |||||||||
| NPI: | 1578538443 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WOLF | ||||||||
| FirstName: | FREDERICK | ||||||||
| MiddleName: | GREGORY | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6077 PRIMACY PKWY STE 140 | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381195742 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9017258347 | ||||||||
| FaxNumber: | 9012597637 | ||||||||
| Practice Location | |||||||||
| Address1: | 1244 PRIMACY PKWY | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381190201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9017678662 | ||||||||
| FaxNumber: | 9017678666 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/22/2006 | ||||||||
| LastUpdateDate: | 04/28/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 36520 | TN | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207XX0005X | 36520 | TN | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine |
ID Information
| ID | Type | State | Issuer | Description | 7951429 | 01 | TN | AETNA | OTHER | 3874732 | 05 | TN | MEDICAID | 00002219069 05 | 01 | TN | UNITED HEALTHCARE | OTHER | 36520 | 01 | TN | TN LICENSE | OTHER | 0995742 | 01 | TN | CIGNA | OTHER | 4179731 | 01 | TN | BCBS | OTHER | 620819926 | 01 | TN | CIGNA | OTHER | P00624366 | 01 | TN | RAILROAD MEDICARE | OTHER | 07187860 | 05 | MS | MEDICAID | 620819926 | 01 | TN | AETNA | OTHER |