Provider Demographics
NPI:1770563009
Name:WAGENER, OSVALDO (MD)
Entity type:Individual
Prefix:DR
First Name:OSVALDO
Middle Name:
Last Name:WAGENER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 SUPERIOR ST
Mailing Address - Street 2:SUITE 204
Mailing Address - City:MELROSE PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60160-4138
Mailing Address - Country:US
Mailing Address - Phone:708-223-7920
Mailing Address - Fax:708-338-1780
Practice Address - Street 1:1111 SUPERIOR ST
Practice Address - Street 2:SUITE 204
Practice Address - City:MELROSE PARK
Practice Address - State:IL
Practice Address - Zip Code:60160-4138
Practice Address - Country:US
Practice Address - Phone:708-223-7920
Practice Address - Fax:708-338-1780
Is Sole Proprietor?:No
Enumeration Date:2006-01-20
Last Update Date:2017-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036086015207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036086015Medicaid
IL01636011OtherBCBS PROVIDER ID
IL36320OtherADVOCATE HLTH CENTERS ID
ILP00291677OtherRAILROAD MEDICARE
ILIL7759001Medicare PIN
ILP00291677OtherRAILROAD MEDICARE
IL36320OtherADVOCATE HLTH CENTERS ID