Provider Demographics
NPI:1831134964
Name:WAGNER, PHILIP J (MD)
Entity Type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:J
Last Name:WAGNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:GPO BOX 27578
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10087-7578
Mailing Address - Country:US
Mailing Address - Phone:631-329-6925
Mailing Address - Fax:631-329-6951
Practice Address - Street 1:535 E 70TH ST
Practice Address - Street 2:HSS DEPT. OF ANESTHESIOLOGY
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021-4823
Practice Address - Country:US
Practice Address - Phone:212-606-1036
Practice Address - Fax:212-517-4481
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2021-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY206778207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01914910Medicaid
NY01914910Medicaid
G41043Medicare UPIN