Basic Information
| Provider Information | |||||||||
| NPI: | 1053372987 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WAGNER | ||||||||
| FirstName: | CHRISTIAN | ||||||||
| MiddleName: | T | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 630 PLANTATION ST | ||||||||
| Address2: | ATTN PHYSICIAN SERVICES WOT 12TH FLOOR | ||||||||
| City: | WORCESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 01605 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5083685529 | ||||||||
| FaxNumber: | 5083685530 | ||||||||
| Practice Location | |||||||||
| Address1: | 135 GOLD STAR BLVD | ||||||||
| Address2: | |||||||||
| City: | WORCESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 01606 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5088532716 | ||||||||
| FaxNumber: | 5088569025 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/30/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 202641 | MA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 3204235 | 01 | MEDICAID WELFARE | OTHER | 44949 | 01 | FALLON COMMUNITY HEALTH P | OTHER | 784219 | 01 | MVP HEALTH CARE | OTHER | A30514 | 01 | MEDICARE B | OTHER | 7370306 | 01 | AETNA US HEALTHCARE | OTHER | 3204235 | 01 | HEALTHY START | OTHER | 3204235 | 05 | MA | MEDICAID | 7200046 | 01 | CIGNA HEALTH PLAN | OTHER | AA5533 | 01 | HARVARD PILGRIM HEALTHCAR | OTHER | J21993 | 01 | BLUE SHIELD INDEMNITY | OTHER | 1818742 | 01 | FIRST HEALTH | OTHER | J21993 | 01 | BLUE CARE ELECT | OTHER | J21993 | 01 | BLUE SHIELD HMO BLUE | OTHER |