Provider Demographics
NPI:1780908731
Name:WAGNER, CHRISTOPHER J
Entity type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:J
Last Name:WAGNER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:52 RISING SUN TOWN CTR
Practice Address - Street 2:
Practice Address - City:RISING SUN
Practice Address - State:MD
Practice Address - Zip Code:21911-1902
Practice Address - Country:US
Practice Address - Phone:410-657-0100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-19
Last Update Date:2012-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEJ10002581225100000X
MD23588225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDP01033233OtherMEDICARE RAILROAD
MDP01033233OtherMEDICARE RAILROAD
DE177164Y0XMedicare PIN