Provider Demographics
NPI:1912989252
Name:WAGER, RICHARD (PHYSICAL THERAPIST)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:WAGER
Suffix:
Gender:M
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2346 MASCOUTAH AVE
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62220-3499
Mailing Address - Country:US
Mailing Address - Phone:618-277-6282
Mailing Address - Fax:618-277-6284
Practice Address - Street 1:2346 MASCOUTAH AVE
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62220-3499
Practice Address - Country:US
Practice Address - Phone:618-277-6282
Practice Address - Fax:618-277-6284
Is Sole Proprietor?:No
Enumeration Date:2005-11-14
Last Update Date:2016-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0700047452251S0007X
IL0960007352255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL436500Medicare ID - Type Unspecified