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General NPI Number Information
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NPI Number | 1497047567
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Entity Type | Individual
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Provider Name | BENJAMIN J WAGNER DO
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Gender | Male
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Dates
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Enumeration Date | 05/09/2011
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Last Update Date | 02/11/2021
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Provider Practice Location Address
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Address Line | 405 W JACKSON ST
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City | CARBONDALE
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State | IL
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Zip | 62901-1462
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Country | US
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Telephone | 618-549-0721
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Fax | 618-457-0469
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Provider Business Mailing Address
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Address Line | 1086 FRANKLIN ST
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City | JOHNSTOWN
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State | PA
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Zip | 15905-4305
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Country | US
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Telephone | 814-534-3745
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Fax | 814-534-5677
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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 | 207P00000X
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Taxonomy Name | Emergency Medicine Physician
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License Number | OS016686
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License Number State | PA
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Taxonomy #2
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Taxonomy Code | 207P00000X
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Taxonomy Name | Emergency Medicine Physician
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License Number | 036140784
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License Number State | IL
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