Provider Demographics
NPI:1528036985
Name:WAGNER, ANDREW F (MD)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:F
Last Name:WAGNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:675 N SAINT CLAIR ST STE 14-200
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-5966
Mailing Address - Country:US
Mailing Address - Phone:312-472-4151
Mailing Address - Fax:312-472-4564
Practice Address - Street 1:675 N SAINT CLAIR ST
Practice Address - Street 2:GALTER 14-200
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-5975
Practice Address - Country:US
Practice Address - Phone:312-695-7269
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-10
Last Update Date:2019-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036141407207SG0201X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No207SG0201XAllopathic & Osteopathic PhysiciansMedical GeneticsClinical Genetics (M.D.)