Provider Demographics
NPI:1538172077
Name:WAGNER, MARTIN HENRY (MD)
Entity type:Individual
Prefix:DR
First Name:MARTIN
Middle Name:HENRY
Last Name:WAGNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:5651 FRIST BLVD
Mailing Address - Street 2:SUITE 413
Mailing Address - City:HERMITAGE
Mailing Address - State:TN
Mailing Address - Zip Code:37076-2054
Mailing Address - Country:US
Mailing Address - Phone:615-885-0110
Mailing Address - Fax:615-885-8110
Practice Address - Street 1:5651 FRIST BLVD
Practice Address - Street 2:SUITE 413
Practice Address - City:HERMITAGE
Practice Address - State:TN
Practice Address - Zip Code:37076-2054
Practice Address - Country:US
Practice Address - Phone:615-885-0110
Practice Address - Fax:615-885-8110
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-14
Last Update Date:2009-11-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TN157062084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3009875Medicaid
TNA97416Medicare UPIN