1770563009 NPI number — DR. OSVALDO WAGENER M.D.

Table of content: DR. OSVALDO WAGENER M.D. (NPI 1770563009)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770563009 NPI number — DR. OSVALDO WAGENER M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WAGENER
Provider First Name:
OSVALDO
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1770563009
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/10/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1111 SUPERIOR ST
Provider Second Line Business Mailing Address:
SUITE 204
Provider Business Mailing Address City Name:
MELROSE PARK
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60160-4138
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
708-223-7920
Provider Business Mailing Address Fax Number:
708-338-1780

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1111 SUPERIOR ST
Provider Second Line Business Practice Location Address:
SUITE 204
Provider Business Practice Location Address City Name:
MELROSE PARK
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60160-4138
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
708-223-7920
Provider Business Practice Location Address Fax Number:
708-338-1780
Provider Enumeration Date:
01/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RN0300X , with the licence number:  036086015 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 036086015 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 01636011 . This is a "BCBS PROVIDER ID" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 36320 . This is a "ADVOCATE HLTH CENTERS ID" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: P00291677 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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