Individual
DR. BENJAMIN J WAGNER
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
DO
Contact information
Practice address
405 W JACKSON ST, CARBONDALE, IL 62901-1462
(618) 549-0721
(618) 457-0469
Mailing address
1086 FRANKLIN ST, JOHNSTOWN, PA 15905-4305
(814) 534-3745
(814) 534-5677
Taxonomy
Speciality
Code
Description
License number
State
207P00000X
Emergency Medicine Physician
Primary
036140784
IL
207P00000X
Emergency Medicine Physician
OS016686
PA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
036140784
—
IL
Enumeration date
05/09/2011
Last updated
02/11/2021
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