Healthcare Provider Details

I. General information

NPI: 1073576336
Provider Name (Legal Business Name): RICHARD F WAGNER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2006
Last Update Date: 04/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

252 MCHENRY ST
BURLINGTON WI
53105-1828
US

IV. Provider business mailing address

4220 WILDERNESS DR
MOUNT PLEASANT WI
53403-4416
US

V. Phone/Fax

Practice location:
  • Phone: 262-767-6100
  • Fax:
Mailing address:
  • Phone: 262-554-0328
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number20111
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: