Provider Demographics
NPI:1821230590
Name:WAGNER, STEPHANIE (MD)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:WAGNER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7435 W TALCOTT AVE
Mailing Address - Street 2:RESURRECTION EMERGENCY MEDICINE RESIDENCY
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60631-3707
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7435 W TALCOTT AVE
Practice Address - Street 2:RESURRECTION EMERGENCY MEDICINE RESIDENCY
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60631-3707
Practice Address - Country:US
Practice Address - Phone:773-792-7921
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-03-27
Last Update Date:2021-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125055080207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine