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General NPI Number Information
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NPI Number | 1154308039
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Entity Type | Individual
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Provider Name | ROBERT WAGNER MD
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Gender | Male
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Dates
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Enumeration Date | 12/30/2005
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Last Update Date | 04/23/2021
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Provider Practice Location Address
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Address Line | 2160 S 1ST AVE (MCGAW ENT., RM 47)
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City | MAYWOOD
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State | IL
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Zip | 60153
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Country | US
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Telephone | 708-216-5221
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Fax | 708-216-0899
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Provider Business Mailing Address
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Address Line | 2160 S 1ST AVE (MCGAW ENT., RM 47)
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City | MAYWOOD
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State | IL
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Zip | 60153
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Country | US
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Telephone | 708-216-5221
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Fax | 708-216-0899
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2085N0904X
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Taxonomy Name | Nuclear Radiology Physician
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License Number | 36071977
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License Number State | IL
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