MEDICARE: THOMAS WAGNER DO

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	207Q00000X	Family Medicine Physician	34007204	OH

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P00103662	OTHER	OH	RR MEDICARE

Other Identifiers

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

General Provider Information

NPI Number	:	1669464673
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	THOMAS WAGNER DO

Provider Business Mailing Address
First Line	:	26908 DETROIT RD
Second Line	:	SUITE 301
City	:	WESTLAKE
State	:	OH
Zip	:	44145-2398
Country	:	US
Telephone Number	:	440-617-1823
Fax Number	:	440-617-0884

Provider Business Practice Location Address
First Line	:	34960 CENTER RIDGE RD
Second Line	:
City	:	N RIDGEVILLE
State	:	OH
Zip	:	44039-3183
Country	:	US
Telephone Number	:	440-353-3433
Fax Number	:	440-353-3431

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

Provider Enumeration Date	:	08/16/2005
Last Update Date	:	11/06/2020

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Directions to “ THOMAS WAGNER DO” Practice Location

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