Provider Demographics
NPI:1912073743
Name:THE SANGER CLINIC PA
Entity type:Organization
Organization Name:THE SANGER CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO-ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:L
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:704-373-0212
Mailing Address - Street 1:1001 BLYTHE BLVD STE 300
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28203-5863
Mailing Address - Country:US
Mailing Address - Phone:704-373-0212
Mailing Address - Fax:704-373-2626
Practice Address - Street 1:1001 BLYTHE BLVD STE 300
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28203-5863
Practice Address - Country:US
Practice Address - Phone:704-373-0212
Practice Address - Fax:704-373-2626
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC133V00000X, 207R00000X, 207RC0000X, 207RC0001X, 207RI0011X, 2080P0202X, 2086S0120X, 2086S0129X, 208G00000X, 363AM0700X, 363AS0400X, 363LA2100X, 363LA2200X, 363LF0000X, 363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Not Answered207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
Not Answered207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac ElectrophysiologyGroup - Multi-Specialty
Not Answered207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional CardiologyGroup - Multi-Specialty
Not Answered2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric CardiologyGroup - Multi-Specialty
Not Answered2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric SurgeryGroup - Multi-Specialty
Not Answered2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty
Not Answered208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Multi-Specialty
Not Answered363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty
Not Answered363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Multi-Specialty
Not Answered363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute CareGroup - Multi-Specialty
Not Answered363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Multi-Specialty
Not Answered363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Not Answered363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP0129Medicaid
NC8902815Medicaid
NC02815OtherBCBS
SC028150Medicaid
SCGP0129Medicaid
NC2311054Medicare ID - Type Unspecified