Provider Demographics
NPI:1477515807
Name:WAGNER, ANNETTE M (MD)
Entity Type:Individual
Prefix:
First Name:ANNETTE
Middle Name:M
Last Name:WAGNER
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:2300 CHILDREN'S PLAZA
Mailing Address - Street 2:#107
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614
Mailing Address - Country:US
Mailing Address - Phone:312-227-6060
Mailing Address - Fax:312-227-9402
Practice Address - Street 1:2301 ENTERPRISE DRIVE
Practice Address - Street 2:#81
Practice Address - City:WESTCHESTER
Practice Address - State:IL
Practice Address - Zip Code:60154
Practice Address - Country:US
Practice Address - Phone:708-836-4800
Practice Address - Fax:708-836-4805
Is Sole Proprietor?:No
Enumeration Date:2006-04-03
Last Update Date:2011-09-21
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IL036089005207NP0225X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207NP0225XAllopathic & Osteopathic PhysiciansDermatologyPediatric Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036089005Medicaid
ILL33309Medicare ID - Type Unspecified
IL036089005Medicaid