Healthcare Provider Details

I. General information

NPI: 1245458355
Provider Name (Legal Business Name): WAGONER MEDICAL CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/23/2007
Last Update Date: 05/15/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2016 W SYCAMORE
KOKOMO IN
46901
US

IV. Provider business mailing address

605 E 7TH STREET
BURLINGTON IN
46915-0038
US

V. Phone/Fax

Practice location:
  • Phone: 765-566-3303
  • Fax:
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

VIII. Authorized Official

Name: MICHELLE WAGONER
Title or Position: ADMINISTRATOR
Credential:
Phone: 765-566-3303