Healthcare Provider Details

I. General information

NPI: 1154308039
Provider Name (Legal Business Name): ROBERT WAGNER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/30/2005
Last Update Date: 04/23/2021
Certification Date: 04/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2160 S 1ST AVE (MCGAW ENT., RM 47)
MAYWOOD IL
60153
US

IV. Provider business mailing address

2160 S 1ST AVE (MCGAW ENT., RM 47)
MAYWOOD IL
60153
US

V. Phone/Fax

Practice location:
  • Phone: 708-216-5221
  • Fax: 708-216-0899
Mailing address:
  • Phone: 708-216-5221
  • Fax: 708-216-0899

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085N0904X
TaxonomyNuclear Radiology Physician
License Number36071977
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: