Provider Demographics
NPI:1396781407
Name:WAGNER, SCOTT A (MD)
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:A
Last Name:WAGNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5301 VIRGINIA WAY
Mailing Address - Street 2:300
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-7541
Mailing Address - Country:US
Mailing Address - Phone:615-221-4474
Mailing Address - Fax:615-234-3774
Practice Address - Street 1:5301 VIRGINIA WAY
Practice Address - Street 2:300
Practice Address - City:BRENTWOOD
Practice Address - State:TN
Practice Address - Zip Code:37027-7541
Practice Address - Country:US
Practice Address - Phone:615-221-4474
Practice Address - Fax:615-234-3774
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2012-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN1036220207ZF0201X, 207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No207ZF0201XAllopathic & Osteopathic PhysiciansPathologyForensic Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP00685220OtherRAILROAD MEDICARE
IN000000487827OtherANTHEM BC/BS
IN100324330Medicaid
OH2673665Medicaid
IN000000587063OtherBLUE CROSS BLUE SHIELD
IN136140AAMedicare PIN
F43422Medicare UPIN
INP00685220OtherRAILROAD MEDICARE