Provider Demographics
NPI:1205819232
Name:WAGNER, CHARLES
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:WAGNER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 HOT METAL ST
Mailing Address - Street 2:QUANTUM ONE SUITE 001
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15203-2348
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1000 S MERCER ST
Practice Address - Street 2:4TH FLOOR
Practice Address - City:NEW CASTLE
Practice Address - State:PA
Practice Address - Zip Code:16101-4672
Practice Address - Country:US
Practice Address - Phone:724-656-6090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-23
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS015833207R00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2204162OtherOHIO MEDICIAD MOLINA
OH000000255057OtherOH MEDICAID UNISON
OH2204162Medicaid
OH310917085192OtherOH MEDICAID CARESOURCE
WV3810013540Medicaid
OH000000255057OtherOH MEDICAID UNISON
OH310917085192OtherOH MEDICAID CARESOURCE