MEDICARE: DR. RICHARD GEORGE WAGNER JR. M.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
1	208000000X	Pediatrics Physician	MD40355	SC

General Provider Information

NPI Number	:	1750380499
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RICHARD GEORGE WAGNER JR. M.D.

Provider Business Mailing Address
First Line	:	519 OCEAN BLVD
Second Line	:
City	:	ISLE OF PALMS
State	:	SC
Zip	:	29451-2132
Country	:	US
Telephone Number	:	404-735-1730
Fax Number	:

Provider Business Practice Location Address
First Line	:	519 OCEAN BLVD
Second Line	:
City	:	ISLE OF PALMS
State	:	SC
Zip	:	29451-2132
Country	:	US
Telephone Number	:	404-735-1730
Fax Number	:

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

Provider Enumeration Date	:	07/15/2005
Last Update Date	:	03/17/2017

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Directions to “ DR. RICHARD GEORGE WAGNER JR. M.D.” Practice Location

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