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Individual

DR. FREDERICK WAGNER

Active
Sole proprietor
No

Provider details

NPI number
Gender
Man
Credential
M.D.

Contact information

Practice address
5921 MERIDIAN WOODS DRIVE, GLEN CARBON, IL 62034-1545
(618) 391-5883
Mailing address
150 BLUFF AVE, NORTH AUGUSTA, SC 29841-3862
(800) 394-4445
(706) 396-3252

Taxonomy

Speciality
Code
Description
License number
State
207L00000X
Anesthesiology Physician
Primary
036124604
IL
207L00000X
Anesthesiology Physician
113352
MO

Other

Other identifiers
Code
Description
Identifier
Issuer
State
05
1770589053
IL
05
205374309
MO
Enumeration date
06/22/2005
Last updated
04/14/2017
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