Basic Information
| Provider Information | |||||||||
| NPI: | 1841221660 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WAGNER | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | W. | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 18101 OAKWOOD BLVD | ||||||||
| Address2: | TRAUMA SERVICES DEPT | ||||||||
| City: | DEARBORN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481232500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3139825440 | ||||||||
| FaxNumber: | 3139825445 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 HURLEY PLZ | ||||||||
| Address2: | 7B WEST BLDG | ||||||||
| City: | FLINT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 485035902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8102629355 | ||||||||
| FaxNumber: | 8107609954 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2006 | ||||||||
| LastUpdateDate: | 08/26/2015 | ||||||||
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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 | 2086S0127X | 4301054569 | MI | Y | Allopathic & Osteopathic Physicians | Surgery | Trauma Surgery | 2086S0102X | 4301054569 | MI | N | Allopathic & Osteopathic Physicians | Surgery | Surgical Critical Care |
ID Information
| ID | Type | State | Issuer | Description | 4511761 | 05 | MI | MEDICAID | 0B56029 | 01 | MI | BLUE SHIELD OF MI | OTHER |