Basic Information
| Provider Information | |||||||||
| NPI: | 1396781407 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WAGNER | ||||||||
| FirstName: | SCOTT | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5301 VIRGINIA WAY | ||||||||
| Address2: | 300 | ||||||||
| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370277541 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6152214474 | ||||||||
| FaxNumber: | 6152343774 | ||||||||
| Practice Location | |||||||||
| Address1: | 5301 VIRGINIA WAY | ||||||||
| Address2: | 300 | ||||||||
| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370277541 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6152214474 | ||||||||
| FaxNumber: | 6152343774 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2006 | ||||||||
| LastUpdateDate: | 01/09/2012 | ||||||||
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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 | 207ZF0201X | 1036220 | IN | N | Allopathic & Osteopathic Physicians | Pathology | Forensic Pathology | 207ZP0102X | 1036220 | IN | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | P00685220 | 01 | IN | RAILROAD MEDICARE | OTHER | 000000487827 | 01 | IN | ANTHEM BC/BS | OTHER | 100324330 | 05 | IN | MEDICAID | 2673665 | 05 | OH | MEDICAID | 000000587063 | 01 | IN | BLUE CROSS BLUE SHIELD | OTHER |