Provider Demographics
NPI:1013964162
Name:WAGONER MEDICAL GROUP PC
Entity Type:Organization
Organization Name:WAGONER MEDICAL GROUP PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JODY
Authorized Official - Middle Name:M
Authorized Official - Last Name:HUGHES
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:308-382-2010
Mailing Address - Street 1:800 N ALPHA ST
Mailing Address - Street 2:
Mailing Address - City:GRAND ISLAND
Mailing Address - State:NE
Mailing Address - Zip Code:68803-4320
Mailing Address - Country:US
Mailing Address - Phone:308-382-2010
Mailing Address - Fax:308-382-9549
Practice Address - Street 1:800 N ALPHA ST
Practice Address - Street 2:
Practice Address - City:GRAND ISLAND
Practice Address - State:NE
Practice Address - Zip Code:68803-4320
Practice Address - Country:US
Practice Address - Phone:308-382-2010
Practice Address - Fax:308-382-9549
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-27
Last Update Date:2008-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE207R00000X, 207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NECD3724OtherMEDICARE GROUP RAILROAD
NE900044Medicare PIN