Mitchel Alan Wagner, DO

Primary specialty

Emergency Medicine PhysicianTaxonomy code 207P00000X

License

036166029 Issued in IL

Practice address

530 NE Glen Oak Ave
Peoria, IL 61637-0001

Phone

(309) 655-2109

NPI assigned

May 14, 2021

Sex

Male

Sole proprietor

No

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

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Enrolled in WA

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

Specialty

Emergency Medicine

Education

Pacific NW Un of HS, Col of Osteopathic Medicine, 2021

Medicare assignment

Accepts the Medicare-approved amount as payment in full

Group practices

Prosser Public Hospital District of Benton CountyGroup PAC ID 6709787872, 111 clinicians

Northwest Emergency Physicians LLCGroup PAC ID 3476462334, 267 clinicians

Practice addresses (Care Compare)

Hospital & facility affiliations

• Prosser Memorial Hospital Hospital, Prosser, WA, CCN 501312
• Kadlec Regional Medical Center Hospital, Richland, WA, CCN 500058

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Osteopathy

State licenses

Practice roles

Locations

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.

• Northwest Emergency Physicians LLC

  • Emergency Medicine Physician
  • Arlington, WA
  • NPI 1235172370
  Medicare reassignment Care Compare group NPD
• Prosser Public Hospital District of Benton County

  • Critical Access Hospital
  • Prosser, WA
  • NPI 1306897681
  Medicare reassignment Care Compare group NPD
• Prosser Public Hospital District of Benton County

  • Specialist
  • Walla Walla, WA
  • NPI 1518770155
  NPD

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

• Kadlec Regional Medical Center

  • General Acute Care Hospital
  • Richland, WA
  • NPI 1972507580
  Care Compare affiliation
• Prosser Public Hospital District of Benton County

  • Critical Access Hospital
  • Prosser, WA
  • NPI 1306897681
  Care Compare affiliation

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

{
    "created_epoch": "1620950400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1696291200000",
    "number": "1609440684",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "530 NE GLEN OAK AVE",
            "city": "PEORIA",
            "state": "IL",
            "postal_code": "616370001",
            "telephone_number": "309-655-2109"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "530 NE GLEN OAK AVE",
            "city": "PEORIA",
            "state": "IL",
            "postal_code": "616370001",
            "telephone_number": "309-655-2109"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WAGNER",
        "first_name": "MITCHEL",
        "middle_name": "ALAN",
        "credential": "DO",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2021-05-14",
        "last_updated": "2023-10-03",
        "certification_date": "2023-10-03",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207P00000X",
            "taxonomy_group": "",
            "desc": "Emergency Medicine",
            "state": "IL",
            "license": "036166029",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Jill Louise Wagenbach, APRN-BC, CNP
• Benjamin Louis Wagner, DO
• Grace Elizabeth Wagner, DNP, APRN, CPNP
• Jenny Wagner
• Julie Wagner
• Ellie Marie Waibel, LSW
• Shan Eve Waid, PTA
• Andrea Wainright, PTA
• Kathryn Leigh Waits, LMT
• Tonya S Wake, MT

• Emergency Medicine Physician in Peoria, IL
• Providers in Peoria, IL by specialty
• Emergency Medicine Physician in Illinois

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 3, 2023; 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.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.