NPIMap

Individual provider Active NPI

Benjamin J Wagner, DO

  • Emergency Medicine Physician
  • Carbondale, IL
National Provider Identifier
1497047567
Registry record updated Feb 11, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Emergency Medicine PhysicianTaxonomy code 207P00000X
License
036140784 Issued in IL
Practice address
405 W Jackson St
Carbondale, IL 62901-1462
Phone
(618) 549-0721
Fax
(618) 457-0469
NPI assigned
May 9, 2011
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Feb 11, 2021

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

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Emergency Medicine Physician 207P00000X OS016686 PA
Emergency Medicine Physician 207P00000X 036140784 IL Primary

Addresses

Primary practice location

405 W Jackson St
Carbondale, IL 62901-1462

Mailing address

1086 Franklin St
Johnstown, PA 15905-4305
Phone (814) 534-3745

Other practice location 1

2 S Hospital Dr
Murphysboro, IL 62966-3333
Phone (618) 684-3156

Other practice location 2

201 S 14th St
Herrin, IL 62948-3631
Phone (618) 942-2171

Other identifiers 1

IdentifierTypeStateIssuer
036140784MedicaidIL

Electronic endpoints 3

TypeEndpointUseAffiliation
Direct Messaging Address bwagner13716@sih.direct-ci.com
Direct Messaging Address bwagner13716@sih.direct-ci.com
Direct Messaging Address bwagner13716@sih.direct-ci.com

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in IL
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20160719000295 IL Practitioner - Emergency Medicine 5799914495 Reassigns benefits to 1 organization

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Doctor of Osteopathy

State licenses

LicenseStateTypeSpecialty
OS016686PAMDEmergency Medicine Physician

Practice roles

OrganizationSpecialtyStatusNew patients
Southern Illinois Medical Services, NFP CurrentSince Jul 1, 2016 Accepting new patients
Windber Hospital, Inc. Past Accepting new patients

Locations

405 W Jackson St
Carbondale, IL 62901

2601 W Main St
Carbondale, IL 62901
Phone (618) 351-7300

201 S 14th St
Herrin, IL 62948
Phone (618) 942-2171

2 S Hospital Dr
Murphysboro, IL 62966
Phone (618) 684-3156

Interoperability endpoints

  • Direct secure messaging: bwagner13716@sih.direct-ci.com

Organizations & group practices 9

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.

Hospital & facility affiliations 2

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

Care Compare profile

Medicare Care Compare
Specialty
Emergency Medicine
Education
Lake Erie College of Osteopathic Medicine, Erie, 2011
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices
Southern Illinois Medical Services NFP 331 clinicians

Practice addresses (Care Compare)

405 W Jackson St
Carbondale, IL 62901-1462
Phone (618) 549-0721

Hospital & facility affiliations

  • Memorial Hospital of Carbondale Hospital, Carbondale, IL, CCN 140164
  • Herrin Hospital Hospital, Herrin, IL, CCN 140011

Merit-based Incentive Payment System (MIPS)

Final score
82 of 100Reported as group
Quality
55.9
Promoting interoperability
100
Improvement activities
40
Cost
72.01

NPI Registry JSON

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

{
    "created_epoch": "1304899200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1613001600000",
    "number": "1497047567",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1086 FRANKLIN ST",
            "city": "JOHNSTOWN",
            "state": "PA",
            "postal_code": "159054305",
            "telephone_number": "814-534-3745",
            "fax_number": "814-534-5677"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "405 W JACKSON ST",
            "city": "CARBONDALE",
            "state": "IL",
            "postal_code": "629011462",
            "telephone_number": "618-549-0721",
            "fax_number": "618-457-0469"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "2 S Hospital Dr",
            "address_purpose": "LOCATION",
            "city": "Murphysboro",
            "state": "IL",
            "postal_code": "629663333",
            "country_code": "US",
            "telephone_number": "618-684-3156",
            "fax_number": "618-529-0524",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "201 S 14th St",
            "address_purpose": "LOCATION",
            "city": "Herrin",
            "state": "IL",
            "postal_code": "629483631",
            "country_code": "US",
            "telephone_number": "618-942-2171",
            "fax_number": "618-988-6186",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "WAGNER",
        "first_name": "BENJAMIN",
        "middle_name": "J",
        "name_prefix": "Dr.",
        "credential": "DO",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2011-05-09",
        "last_updated": "2021-02-11",
        "certification_date": "2021-02-11",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207P00000X",
            "taxonomy_group": "",
            "desc": "Emergency Medicine",
            "state": "PA",
            "license": "OS016686",
            "primary": false
        },
        {
            "code": "207P00000X",
            "taxonomy_group": "",
            "desc": "Emergency Medicine",
            "state": "IL",
            "license": "036140784",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "036140784",
            "state": "IL"
        }
    ],
    "endpoints": [
        {
            "endpointType": "DIRECT",
            "endpointTypeDescription": "Direct Messaging Address",
            "endpoint": "bwagner13716@sih.direct-ci.com",
            "affiliation": "N",
            "address_1": "2 S Hospital Dr",
            "city": "Murphysboro",
            "state": "IL",
            "country_code": "US",
            "postal_code": "629663333",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "endpointType": "DIRECT",
            "endpointTypeDescription": "Direct Messaging Address",
            "endpoint": "bwagner13716@sih.direct-ci.com",
            "affiliation": "N",
            "address_1": "405 W Jackson St",
            "city": "Carbondale",
            "state": "IL",
            "country_code": "US",
            "postal_code": "629011462",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "endpointType": "DIRECT",
            "endpointTypeDescription": "Direct Messaging Address",
            "endpoint": "bwagner13716@sih.direct-ci.com",
            "affiliation": "N",
            "address_1": "201 S 14th St",
            "city": "Herrin",
            "state": "IL",
            "country_code": "US",
            "postal_code": "629483631",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

Other providers in Carbondale, IL

Sources for this page

Verify at the official NPI Registry.