NPIMap

Organization Active NPI

Wagner Medical Clinic L.L.P.

Doing business as Moulton Clinic

  • Rural Health Clinic/Center
  • Moulton, TX
National Provider Identifier
1356322127
Registry record updated Nov 2, 2017
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
WAGNER MEDICAL CLINIC L.L.P.
Doing business as
Moulton Clinic
Practice address
100 S Pecan
Moulton, TX 77975-0238
Phone
(361) 594-3824
NPI assigned
Nov 9, 2005
Last updated
Nov 2, 2017By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Nov 2, 2017

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

Authorized official

Name
Ralph Wagner, MDNPI 1447231881
Title
MD
Phone
(361) 594-3824

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Rural Health Clinic/Center 261QR1300X Primary
Physician Assistant 363A00000X PA11615

Addresses

Primary practice location

100 S Pecan
Moulton, TX 77975-0238

Mailing address

PO Box 965
Shiner, TX 77984-0965
Phone (361) 594-3824

Other identifiers 1

IdentifierTypeStateIssuer
063662301MedicaidTX

Other names 1

  • Moulton Clinic Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in TX

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20041007000509 TX Part A Provider - Rural Health Clinic 9335108091 Practice locations: Moulton, TX

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1356322127. Details of each certification follow.

Rural health clinic certification: CCN 458968

Legal name
WAGNER MEDICAL CLINIC L.L.P.
Doing business as
MOULTON CLINIC
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Jul 30, 1997
Last certification
Jun 16, 2015
Ownership / control type
1C
Organization structure
PartnershipNon-profit
Enrollment address
100 S Pecan St
Wagner Medical Clinic L.L.P.
Moulton, TX 77975-0238

Other NPIs with the same Medicare PAC ID 1

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

National Provider Directory

National Provider Directory
Tax ID family
Moulton Clinic2 organizations share this tax ID, including this one

Other organizations with this tax ID 1

Organizations that report the same tax identification number in the National Provider Directory.

Ownership & related parties

All disclosed owners & managing parties 4

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Marshall C Bishop Individual 5% Or Greater Direct Ownership InterestM.D. Sep 1, 2001
Ralph a Wagner Individual General Partnership Interest Oct 8, 2004
Carline Lopez Individual W-2 Managing EmployeeOffice Manager Jan 1, 2024
Timothy J Wagner Individual General Partnership Interest Oct 8, 2004

Owners & managing parties with NPI records 3

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

Practitioners & affiliated clinicians

Practitioners 4

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

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

{
    "created_epoch": "1131494400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1509580800000",
    "number": "1356322127",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 965",
            "city": "SHINER",
            "state": "TX",
            "postal_code": "779840965",
            "telephone_number": "361-594-3824"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "100 S PECAN",
            "city": "MOULTON",
            "state": "TX",
            "postal_code": "779750238",
            "telephone_number": "361-594-3824"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "WAGNER MEDICAL CLINIC L.L.P.",
        "organizational_subpart": "NO",
        "enumeration_date": "2005-11-09",
        "last_updated": "2017-11-02",
        "status": "A",
        "authorized_official_last_name": "WAGNER",
        "authorized_official_first_name": "RALPH",
        "authorized_official_title_or_position": "MD",
        "authorized_official_telephone_number": "361-594-3824",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": null,
            "license": "PA11615",
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "063662301",
            "state": "TX"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Moulton Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Moulton, TX

Sources for this page

Verify at the official NPI Registry.