Provider Demographics
NPI:1306063045
Name:PAUL F WAGNER, MD SC
Entity type:Organization
Organization Name:PAUL F WAGNER, MD SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:F
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:262-763-7613
Mailing Address - Street 1:308 MCHENRY ST
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:WI
Mailing Address - Zip Code:53105-2164
Mailing Address - Country:US
Mailing Address - Phone:262-763-7613
Mailing Address - Fax:262-763-7002
Practice Address - Street 1:308 MCHENRY ST
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:WI
Practice Address - Zip Code:53105-2164
Practice Address - Country:US
Practice Address - Phone:262-763-7613
Practice Address - Fax:262-763-7002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-20
Last Update Date:2009-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI5283910001Medicare NSC
WI181917022Medicare PIN
WIP00683746Medicare PIN
WI0000152555Medicare NSC
WI000065235Medicare PIN