Provider Demographics
NPI:1770589053
Name:WAGNER, FREDERICK (MD)
Entity type:Individual
Prefix:DR
First Name:FREDERICK
Middle Name:
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 1:150 BLUFF AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH AUGUSTA
Mailing Address - State:SC
Mailing Address - Zip Code:29841-3862
Mailing Address - Country:US
Mailing Address - Phone:800-394-4445
Mailing Address - Fax:706-396-3252
Practice Address - Street 1:5921 MERIDIAN WOODS DRIVE
Practice Address - Street 2:
Practice Address - City:GLEN CARBON
Practice Address - State:IL
Practice Address - Zip Code:62034-1545
Practice Address - Country:US
Practice Address - Phone:618-391-5883
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-22
Last Update Date:2017-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO113352207L00000X
IL036124604207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1770589053Medicaid
MO205374309Medicaid
MO055010325Medicare PIN
ILIL3454007Medicare PIN
MO205374309Medicaid