Provider Demographics
NPI:1518957273
Name:WAGNER, CHRISTINA RUTH (MD)
Entity Type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:RUTH
Last Name:WAGNER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:CHRISTINA
Other - Middle Name:RUTH
Other - Last Name:ANDERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:209 NW 11TH ST
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62837-1218
Mailing Address - Country:US
Mailing Address - Phone:618-842-4470
Mailing Address - Fax:618-842-4470
Practice Address - Street 1:103 COMMERCE ST
Practice Address - Street 2:
Practice Address - City:CARMI
Practice Address - State:IL
Practice Address - Zip Code:62821-2223
Practice Address - Country:US
Practice Address - Phone:618-842-4470
Practice Address - Fax:618-842-3437
Is Sole Proprietor?:No
Enumeration Date:2005-10-25
Last Update Date:2015-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036107740208000000X, 207PE0004X
IN01073102A207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036107740Medicaid
ILK21263Medicare PIN
IL036107740Medicaid