Healthcare Provider Details

I. General information

NPI: 1447875042
Provider Name (Legal Business Name): SCOTT WAGNER INTEGRATED MEDICINE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/10/2020
Last Update Date: 06/20/2023
Certification Date: 06/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2109 INDIA RD
CHARLOTTESVILLE VA
22901-2886
US

IV. Provider business mailing address

2109 INDIA RD
CHARLOTTESVILLE VA
22901-2886
US

V. Phone/Fax

Practice location:
  • Phone: 434-978-4888
  • Fax:
Mailing address:
  • Phone: 434-978-4888
  • Fax: 434-978-3633

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: SCOTT BRIAN WAGNER
Title or Position: AUTHORIZED OFFICIAL
Credential: DC
Phone: 434-978-4888