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NPI Code Detail

MEDICARE: MARILYN M WAGNER PH.D.

MEDICARE: MARILYN M WAGNER PH.D.
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
1103G00000XClinical Neuropsychologist553KY

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1598757213
Entity Type Code : Individual
Provider Name (Legal Business Name) : MARILYN M WAGNER PH.D.
Provider Business Mailing Address
First Line : 7511 NEW LAGRANGE RD
Second Line :
City : LOUISVILLE
State : KY
Zip : 40222-4859
Country : US
Telephone Number : 502-423-1151
Fax Number : 502-423-1748
Provider Business Practice Location Address
First Line : 7511 NEW LAGRANGE RD
Second Line :
City : LOUISVILLE
State : KY
Zip : 40222-4859
Country : US
Telephone Number : 502-423-1151
Fax Number : 502-423-1748
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 08/18/2005
Last Update Date : 07/08/2007

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