Basic Information
| Provider Information | |||||||||
| NPI: | 1184753782 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WAGNER | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6900 PEARL ROAD | ||||||||
| Address2: | 2ND FLOOR | ||||||||
| City: | MIDDLEBURG HEIGHTS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441303639 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4408450900 | ||||||||
| FaxNumber: | 4408457355 | ||||||||
| Practice Location | |||||||||
| Address1: | 6900 PEARL ROAD | ||||||||
| Address2: | 2ND FLOOR | ||||||||
| City: | MIDDLEBURG HEIGHTS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441303639 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4408450900 | ||||||||
| FaxNumber: | 4408457355 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/02/2007 | ||||||||
| LastUpdateDate: | 04/18/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0105X | 35052657 | OH | Y | Allopathic & Osteopathic Physicians | Pathology | Clinical Pathology/Laboratory Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2152138 | 05 | OH | MEDICAID |