Healthcare Provider Details

I. General information

NPI: 1841465002
Provider Name (Legal Business Name): AUDREY KARIN WAGNER MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2008
Last Update Date: 10/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

345 SAINT PAUL ST MERCY MEDICAL CENTER, 9TH FLOOR, ICU
BALTIMORE MD
21202-2123
US

IV. Provider business mailing address

5 CHRIS ELIOT CT
COCKEYSVILLE MD
21030-1525
US

V. Phone/Fax

Practice location:
  • Phone: 410-332-9610
  • Fax:
Mailing address:
  • Phone: 203-249-4367
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberD73965
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number256996
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License NumberD73965
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: