Provider Demographics
NPI:1295735926
Name:WAGNER, KEVIN MATTHEW (MD PT CERT MDT)
Entity type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:MATTHEW
Last Name:WAGNER
Suffix:
Gender:M
Credentials:MD PT CERT MDT
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Mailing Address - Street 1:BACK PAIN INSTITUTE OF ST. LOUIS LLC
Mailing Address - Street 2:11903 ST. CHARLES ROCK RD.
Mailing Address - City:BRIDGETON
Mailing Address - State:MO
Mailing Address - Zip Code:63044
Mailing Address - Country:US
Mailing Address - Phone:314-770-0900
Mailing Address - Fax:314-739-8569
Practice Address - Street 1:11903 SAINT CHARLES ROCK RD
Practice Address - Street 2:
Practice Address - City:BRIDGETON
Practice Address - State:MO
Practice Address - Zip Code:63044-2623
Practice Address - Country:US
Practice Address - Phone:314-770-0900
Practice Address - Fax:314-770-1673
Is Sole Proprietor?:No
Enumeration Date:2005-07-22
Last Update Date:2010-04-29
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MO115026225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO219461637Medicare ID - Type Unspecified