1952664583 NPI number — ALEX FRANCIS WAGNER DO

Table of content: ALEX FRANCIS WAGNER DO (NPI 1952664583)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1952664583 NPI number — ALEX FRANCIS WAGNER DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WAGNER
Provider First Name:
ALEX
Provider Middle Name:
FRANCIS
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
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:
1952664583
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/05/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
600 BROADWAY AVE NW APT 425
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRAND RAPIDS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49504-7324
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
989-387-5540
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6401 PRAIRIE ST
Provider Second Line Business Practice Location Address:
SUITE 1600
Provider Business Practice Location Address City Name:
NORTON SHORES
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49444-7840
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
231-727-7920
Provider Business Practice Location Address Fax Number:
231-727-7921
Provider Enumeration Date:
06/19/2012

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: 207Q00000X , with the licence number:  5101020032 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: N28430113 . This is a "MEDICARE IND PTAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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