Basic Information
| Provider Information | |||||||||
| NPI: | 1669488946 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WAGNER | ||||||||
| FirstName: | RICHARD | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 101 LIONS DR | ||||||||
| Address2: | SUITE 119 | ||||||||
| City: | BARRINGTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600103181 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8478420771 | ||||||||
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| Practice Location | |||||||||
| Address1: | 101 LIONS DR | ||||||||
| Address2: | SUITE 119 | ||||||||
| City: | BARRINGTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600103181 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8478420771 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2006 | ||||||||
| LastUpdateDate: | 03/16/2017 | ||||||||
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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 | 2084P0800X | 036085205 | IL | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | F400331528 | 01 | IL | MEDICARE PTAN INDIVIDUAL | OTHER | 206147 | 01 | IL | MEDICARE PTAN GROUP | OTHER | 036085205 | 01 | IL | MEDICAID | OTHER |