Healthcare Provider Details

I. General information

NPI: 1457421497
Provider Name (Legal Business Name): WAGONER MEDICAL CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2006
Last Update Date: 05/15/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

605 EAST 7TH STREET
BURLINGTON IN
46915-0038
US

IV. Provider business mailing address

PO BOX 38
BURLINGTON IN
46915-0038
US

V. Phone/Fax

Practice location:
  • Phone: 765-566-3351
  • Fax: 765-566-2250
Mailing address:
  • Phone: 765-566-3351
  • Fax: 765-566-2250

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: MICHELLE WAGONER
Title or Position: ADMINISTRATOR
Credential:
Phone: 765-566-3351