Provider Demographics
NPI:1417108051
Name:K. STEVEN WAGNER, MD PLLC
Entity Type:Organization
Organization Name:K. STEVEN WAGNER, MD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JEANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAVES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-652-6640
Mailing Address - Street 1:1500 WALTON BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48309-1858
Mailing Address - Country:US
Mailing Address - Phone:248-652-6640
Mailing Address - Fax:248-652-3914
Practice Address - Street 1:1500 WALTON BLVD
Practice Address - Street 2:
Practice Address - City:ROCHESTER HILLS
Practice Address - State:MI
Practice Address - Zip Code:48309-1858
Practice Address - Country:US
Practice Address - Phone:248-652-6640
Practice Address - Fax:248-652-3914
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-01
Last Update Date:2020-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIKW038400207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
4264336OtherAETNA
MI1798911Medicaid
E26269OtherHAP
160009538OtherRR MEDICARE
160F353410OtherBCBS/BCN
160F353410OtherBCBS/BCN
MIMI1025Medicare PIN