Basic Information
| Provider Information | |||||||||
| NPI: | 1831383074 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WAGNER | ||||||||
| FirstName: | JORDAN | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | FRIZZO | ||||||||
| OtherFirstName: | JORDAN | ||||||||
| OtherMiddleName: | M | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 6416 DEANS HILL RD | ||||||||
| Address2: | |||||||||
| City: | BERRIEN CENTER | ||||||||
| State: | MI | ||||||||
| PostalCode: | 491029750 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2694717741 | ||||||||
| FaxNumber: | 2694711581 | ||||||||
| Practice Location | |||||||||
| Address1: | 2002 S 11TH ST | ||||||||
| Address2: | |||||||||
| City: | NILES | ||||||||
| State: | MI | ||||||||
| PostalCode: | 491204074 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2696870200 | ||||||||
| FaxNumber: | 2696840199 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2007 | ||||||||
| LastUpdateDate: | 03/14/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 5601005116 | MI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1831383074 | 05 | MI | MEDICAID |