Healthcare Provider Details

I. General information

NPI: 1912989252
Provider Name (Legal Business Name): RICHARD WAGER PHYSICAL THERAPIST
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2005
Last Update Date: 07/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2346 MASCOUTAH AVE
BELLEVILLE IL
62220-3499
US

IV. Provider business mailing address

2346 MASCOUTAH AVE
BELLEVILLE IL
62220-3499
US

V. Phone/Fax

Practice location:
  • Phone: 618-277-6282
  • Fax: 618-277-6284
Mailing address:
  • Phone: 618-277-6282
  • Fax: 618-277-6284

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number070004745
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number096000735
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: