Healthcare Provider Details

I. General information

NPI: 1518957273
Provider Name (Legal Business Name): CHRISTINA RUTH WAGNER M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CHRISTINA RUTH ANDERSON

II. Dates (important events)

Enumeration Date: 10/25/2005
Last Update Date: 02/03/2025
Certification Date: 02/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1530 LONE OAK RD
PADUCAH KY
42003-7901
US

IV. Provider business mailing address

209 NW 11TH ST
FAIRFIELD IL
62837-1218
US

V. Phone/Fax

Practice location:
  • Phone: 271-444-2444
  • Fax:
Mailing address:
  • Phone: 618-842-4470
  • Fax: 618-842-4470

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number01073102A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number036107740
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036107740
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: