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General NPI Number Information
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NPI Number | 1861458952
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Entity Type | Individual
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Provider Name | RICHARD W WAGONER M.D.
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Gender | Male
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Dates
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Enumeration Date | 04/26/2006
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Last Update Date | 06/01/2012
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Provider Practice Location Address
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Address Line | 615 N PROMENADE ST
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City | HAVANA
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State | IL
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Zip | 62644-1243
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Country | US
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Telephone | 309-543-6600
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Fax | 309-543-2089
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Provider Business Mailing Address
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Address Line | 615 N PROMENADE ST P O BOX 530
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City | HAVANA
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State | IL
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Zip | 62644-1015
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Country | US
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Telephone | 309-543-6600
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Fax | 309-543-2089
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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 | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | 036104579
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License Number State | IL
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