Basic Information
| Provider Information | |||||||||
| NPI: | 1477633931 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WAGNER | ||||||||
| FirstName: | BRIAN | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5 EAST 98TH STREET BOX 1170 | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100296501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2122415681 | ||||||||
| FaxNumber: | 2123487438 | ||||||||
| Practice Location | |||||||||
| Address1: | 1176 FIFITH AVENUE E LEVEL | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100296501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2126598557 | ||||||||
| FaxNumber: | 2123692385 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2006 | ||||||||
| LastUpdateDate: | 03/22/2012 | ||||||||
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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 | 207V00000X | 225630 | NY | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207VM0101X | 225630 | NY | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Maternal & Fetal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 02532754 | 05 | NY | MEDICAID |