Basic Information
| Provider Information | |||||||||
| NPI: | 1841399441 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WAGNER | ||||||||
| FirstName: | STEVEN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 45 ST LAWRENCE DR | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | TIFFIN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 448838310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4194558501 | ||||||||
| FaxNumber: | 4194558504 | ||||||||
| Practice Location | |||||||||
| Address1: | 45 ST LAWRENCE DR | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | TIFFIN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 448838310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4194558501 | ||||||||
| FaxNumber: | 4194558504 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2006 | ||||||||
| LastUpdateDate: | 07/08/2014 | ||||||||
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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 | 207RG0100X | 35037285 | OH | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 0413127 | 05 | OH | MEDICAID |