Healthcare Provider Details

I. General information

NPI: 1477187383
Provider Name (Legal Business Name): ROY MARSHALL WAGNER DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/29/2020
Last Update Date: 11/07/2023
Certification Date: 11/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 SAINT ELIZABETH BLVD STE 4000
O FALLON IL
62269
US

IV. Provider business mailing address

3 SAINT ELIZABETH BLVD STE 4000
O FALLON IL
62269-1284
US

V. Phone/Fax

Practice location:
  • Phone: 618-233-7880
  • Fax: 618-222-4792
Mailing address:
  • Phone: 618-256-9355
  • Fax: 618-206-2332

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036164627
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: