Provider Demographics
NPI:1700122595
Name:MICHAEL WAGNER, S.C.
Entity Type:Organization
Organization Name:MICHAEL WAGNER, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-987-5450
Mailing Address - Street 1:650 E DIEHL RD
Mailing Address - Street 2:SUITE 121
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60563-4801
Mailing Address - Country:US
Mailing Address - Phone:847-987-5450
Mailing Address - Fax:
Practice Address - Street 1:650 E DIEHL RD
Practice Address - Street 2:SUITE 121
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60563-4801
Practice Address - Country:US
Practice Address - Phone:847-987-5450
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-24
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0426197492084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty