Provider Demographics
NPI:1124180351
Name:WAGNER & WAGNER PSC
Entity Type:Organization
Organization Name:WAGNER & WAGNER PSC
Other - Org Name:WAGNER EYE CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:T
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:O D
Authorized Official - Phone:270-651-8323
Mailing Address - Street 1:PO BOX 638
Mailing Address - Street 2:
Mailing Address - City:GLASGOW
Mailing Address - State:KY
Mailing Address - Zip Code:42142-0638
Mailing Address - Country:US
Mailing Address - Phone:270-651-8323
Mailing Address - Fax:270-651-8324
Practice Address - Street 1:115 COLUMBIA AVE
Practice Address - Street 2:
Practice Address - City:GLASGOW
Practice Address - State:KY
Practice Address - Zip Code:42141-2903
Practice Address - Country:US
Practice Address - Phone:270-651-8323
Practice Address - Fax:270-651-8324
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-14
Last Update Date:2010-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY77900561Medicaid
KYDB9679Medicare PIN
KY77900561Medicaid
KY8202Medicare PIN