=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063473692
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | WILLIAM G WAGNER MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/31/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1601 N TAYLOR DR
-----------------------------------------------------
City | SHEBOYGAN
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53081-1930
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-459-8300
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2108 KOHLER MEMORIAL DR STE 101
-----------------------------------------------------
City | SHEBOYGAN
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53081-3100
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0204X
-----------------------------------------------------
Taxonomy Name | Vascular & Interventional Radiology Physician
-----------------------------------------------------
License Number | 17431020
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------