Basic Information
| Provider Information | |||||||||
| NPI: | 1013025097 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JORDAN-WAGNER | ||||||||
| FirstName: | DIANE | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 221 S 6TH ST | ||||||||
| Address2: | |||||||||
| City: | TERRE HAUTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 478074214 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8122320564 | ||||||||
| FaxNumber: | 8122353330 | ||||||||
| Practice Location | |||||||||
| Address1: | 1429 N 6TH ST | ||||||||
| Address2: | |||||||||
| City: | TERRE HAUTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 478041037 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8122320564 | ||||||||
| FaxNumber: | 8122353330 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2006 | ||||||||
| LastUpdateDate: | 03/14/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RA0201X | 01056292A | IN | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Allergy & Immunology | 207RA0201X | 36106006 | IL | N | Allopathic & Osteopathic Physicians | Internal Medicine | Allergy & Immunology |
ID Information
| ID | Type | State | Issuer | Description | 030005377 | 01 | RAILROAD MCARE PALAMETTO | OTHER | 200392780 | 05 | IN | MEDICAID | P00844293 | 01 | IN | RAILROAD MEDICARE | OTHER | 000000230225 | 01 | ANTHEM | OTHER | 200392780Q | 05 | IN | MEDICAID |