MEDICARE: ANGELA B WAGNER D.O.

Medicare Provider Information

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	204D00000X	Neuromusculoskeletal Medicine & OMM Physician	02002402A	IN
2	207Q00000X	Family Medicine Physician	02002402A	IN
3	207QH0002X	Hospice and Palliative Medicine (Family Medicine) Physician	02002402A	IN

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

NPI Number	:	1710928270
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANGELA B WAGNER D.O.

Provider Business Mailing Address
First Line	:	30 W MONROE ST STE 1200
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60603-2420
Country	:	US
Telephone Number	:	815-861-4302
Fax Number	:	773-866-8014

Provider Business Practice Location Address
First Line	:	5926 CRAWFORDSVILLE RD UNIT B
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46224-3722
Country	:	US
Telephone Number	:	317-653-2730
Fax Number	:	317-321-1935

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

Provider Enumeration Date	:	06/08/2006
Last Update Date	:	08/25/2020

5926 CRAWFORDSVILLE RD UNIT B
INDIANAPOLIS, IN
46224-3722

Practice Phone: 317-653-2730
Practice Fax: 317-623-1440

5926 CRAWFORDSVILLE RD UNIT B
INDIANAPOLIS, IN
46224-3722