MEDICARE: CHARLES WAGNER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	OS015833	PA

General Provider Information

NPI Number	:	1205819232
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHARLES WAGNER

Provider Business Mailing Address
First Line	:	2 HOT METAL ST
Second Line	:	QUANTUM ONE SUITE 001
City	:	PITTSBURGH
State	:	PA
Zip	:	15203-2348
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1000 S MERCER ST
Second Line	:	4TH FLOOR
City	:	NEW CASTLE
State	:	PA
Zip	:	16101-4672
Country	:	US
Telephone Number	:	724-656-6090
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/23/2005
Last Update Date	:	03/25/2021

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