MEDICARE: MR. RICK WAGELIE OTR/L

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	174400000X	Specialist	# 421	NE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	09203	OTHER	NE	BLUE CROSS BLUE SHIELD #
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1942200936
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. RICK WAGELIE OTR/L

Provider Business Mailing Address
First Line	:	5156 S 197TH AVENUE CIR
Second Line	:
City	:	OMAHA
State	:	NE
Zip	:	68135-3679
Country	:	US
Telephone Number	:	402-290-0931
Fax Number	:	402-597-0382

Provider Business Practice Location Address
First Line	:	5156 S 197TH AVENUE CIR
Second Line	:
City	:	OMAHA
State	:	NE
Zip	:	68135-3679
Country	:	US
Telephone Number	:	402-290-0931
Fax Number	:	402-597-0382

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

Provider Enumeration Date	:	07/30/2005
Last Update Date	:	03/18/2015

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