Provider Demographics
NPI:1588773444
Name:WAGNER, TIMOTHY J (PT)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:J
Last Name:WAGNER
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1522 BRISTOL AVE
Mailing Address - Street 2:
Mailing Address - City:WESTCHESTER
Mailing Address - State:IL
Mailing Address - Zip Code:60154-3706
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4861 S 27TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53221-2603
Practice Address - Country:US
Practice Address - Phone:414-325-3325
Practice Address - Fax:414-325-3334
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2009-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL70015254225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI15887734444Medicaid
WI830420024Medicare PIN
ILR01003Medicare PIN
ILR03689Medicare PIN
ILR03690Medicare PIN
WI15887734444Medicaid
WI001183207Medicare PIN