Provider Demographics
NPI:1841474574
Name:DRS WAGNER-DEBRE ASSOCIATES SC
Entity type:Organization
Organization Name:DRS WAGNER-DEBRE ASSOCIATES SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE OWNER (PRESIDENT)
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:W
Authorized Official - Last Name:DEBRE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:708-423-3800
Mailing Address - Street 1:9830 RIDGELAND AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:CHICAGO RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60415-2667
Mailing Address - Country:US
Mailing Address - Phone:708-423-3800
Mailing Address - Fax:
Practice Address - Street 1:9830 RIDGELAND AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:CHICAGO RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60415-2667
Practice Address - Country:US
Practice Address - Phone:708-423-3800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-17
Last Update Date:2009-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036053268207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL36053268Medicaid
IL36053268Medicaid
ILD13815Medicare UPIN