Matthew Robert Wagner, MD

Primary specialty

Pediatric Orthopaedic Surgery PhysicianTaxonomy code 207XP3100X

License

251727 Issued in NY

Practice address

1500 Route 112 BLDG 2C
Port Jefferson Station, NY 11776-8055

Phone

(631) 371-8034

Fax

(631) 828-7899

NPI assigned

Mar 21, 2008

Sex

Male

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Other identifiers 1

Medicare fee-for-service enrollment

Enrolled in NY

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: Yes

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Medicine

State licenses

Practice roles (4 of 8)

Locations

Networks

• Healthfirst Medicare Network H3359
• Healthfirst Medicare Network H1722
• Healthfirst Medicare Network H5989
• Healthfirst Medicare Network H9678

Interoperability endpoints

• Direct secure messaging: mwagner48810@direct-chsli.net

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• CHS Physician Partners, PC

  • Interventional Cardiology Physician
  • Fresh Meadows, NY
  • NPI 1407089345

  NY

  Medicare reassignment NPD
• St Charles Hospital Corp

  • General Acute Care Hospital
  • Port Jefferson, NY
  • NPI 1497765630

  NY

  Medicare reassignment NPD
• CHS Physician Partners, P.C

  • Cardiovascular Disease Physician
  • Roslyn, NY
  • NPI 1164585725
  NPD
• Orthopedic Associates of Long Island LLP

  • Orthopaedic Surgery Physician
  • Commack, NY
  • NPI 1316348683
  NPD

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1206057600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1572912000000",
    "number": "1114198751",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1500 ROUTE 112 BLDG 2C",
            "city": "PORT JEFFERSON STATION",
            "state": "NY",
            "postal_code": "117768055",
            "telephone_number": "631-371-8034",
            "fax_number": "631-828-7899"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1500 ROUTE 112 BLDG 2C",
            "city": "PORT JEFFERSON STATION",
            "state": "NY",
            "postal_code": "117768055",
            "telephone_number": "631-371-8034",
            "fax_number": "631-828-7899"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "500 Commack Rd Unit 150",
            "address_purpose": "LOCATION",
            "city": "Commack",
            "state": "NY",
            "postal_code": "117255009",
            "country_code": "US",
            "telephone_number": "631-371-8034",
            "fax_number": "631-828-7899",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "WAGNER",
        "first_name": "MATTHEW",
        "middle_name": "ROBERT",
        "name_prefix": "Dr.",
        "credential": "MD",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2008-03-21",
        "last_updated": "2019-11-05",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207XP3100X",
            "taxonomy_group": "",
            "desc": "Orthopaedic Surgery, Pediatric Orthopaedic Surgery",
            "state": "FL",
            "license": "ME103612",
            "primary": false
        },
        {
            "code": "207XP3100X",
            "taxonomy_group": "",
            "desc": "Orthopaedic Surgery, Pediatric Orthopaedic Surgery",
            "state": "NY",
            "license": "251727",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICARE",
            "identifier": "120130521000407",
            "state": "NY"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Lisa Volpe, RPH
• Kaitlyn Marie Von Werne
• Diane Voos, LPN
• Holly Ann Vulpis, CF-SLP
• Allysa J Wachholder, LCSW
• Walgreen Co
• Walgreen Co
• Dawn M Walker
• Christine Marie Wall, RN
• Marie E Walsh, RN

• All providers in Port Jefferson Station, NY
• Pediatric Orthopaedic Surgery Physician in New York

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 5, 2019; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.