Provider Demographics
NPI:1982685756
Name:WAGNER MEDICAL CLINIC L.L.P.
Entity Type:Organization
Organization Name:WAGNER MEDICAL CLINIC L.L.P.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:RALPH
Authorized Official - Middle Name:
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:361-594-3824
Mailing Address - Street 1:PO BOX 965
Mailing Address - Street 2:
Mailing Address - City:SHINER
Mailing Address - State:TX
Mailing Address - Zip Code:77984-0965
Mailing Address - Country:US
Mailing Address - Phone:361-594-3824
Mailing Address - Fax:
Practice Address - Street 1:124 E WOLTERS 2ND
Practice Address - Street 2:
Practice Address - City:SHINER
Practice Address - State:TX
Practice Address - Zip Code:77984-7109
Practice Address - Country:US
Practice Address - Phone:361-594-3824
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-09
Last Update Date:2010-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX063629201Medicaid
TX0T01UOtherBLUE CROSS
TX063629201Medicaid