NPIMap

Organization Active NPI

T W Wagner Inc

  • Family Medicine Physician
  • Manila, AR
National Provider Identifier
1720183031
Registry record updated Jul 22, 2016
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
License
E3873 Issued in AR
Legal business name
T W WAGNER INC
Practice address
3644 W State Highway 18
Manila, AR 72442-8049
Phone
(870) 561-3300
Fax
(870) 561-3307
NPI assigned
Sep 13, 2006
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jul 22, 2016

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

Authorized official

Name
Tommy W Wagner Jr., MDNPI 1952385064
Title
Owner
Phone
(870) 561-3300

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
Family Medicine PhysicianGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 207Q00000X E3873 AR Primary
Family Nurse PractitionerGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 363LF0000X A01771 AR

Addresses

Primary practice location

3644 W State Highway 18
Manila, AR 72442-8049

Mailing address

PO Box 910
Manila, AR 72442-0910
Phone (870) 561-3300

Other identifiers 1

IdentifierTypeStateIssuer
156106001MedicaidAR

Other names 1

  • WAGNER MEDICAL CLINIC Doing business as

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20050830000950 AR Part B Supplier - Clinic/Group Practice 1153359096 Receives reassigned benefits from 9 practitioners
Practice locations: Bentonville, AR; Blytheville, AR; Lepanto, AR; Manila, AR

Other NPIs with the same Medicare PAC ID 2

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

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
04D1041996Wagner Medical Clinic3644 West State Hwy 18, Manila, AR 72442Certificate of waiverMar 10, 2028

National Provider Directory

National Provider Directory
Tax ID family
T W Wagner Inc4 organizations share this tax ID, including this one

Other organizations with this tax ID 3

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

Locations

1001 N 6th St
Blytheville, AR 72315
Phone (870) 281-2530

730 Greenwood Ave
#B
Lepanto, AR 72354
Phone (870) 475-3825

3644 W State Highway 18
Ste B
Manila, AR 72442
Phone (870) 561-3300

Practitioners & affiliated clinicians

Practitioners 10

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

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

{
    "created_epoch": "1158105600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1469145600000",
    "number": "1720183031",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 910",
            "city": "MANILA",
            "state": "AR",
            "postal_code": "724420910",
            "telephone_number": "870-561-3300",
            "fax_number": "870-561-3307"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3644 W STATE HIGHWAY 18",
            "city": "MANILA",
            "state": "AR",
            "postal_code": "724428049",
            "telephone_number": "870-561-3300",
            "fax_number": "870-561-3307"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "T W WAGNER INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-09-13",
        "last_updated": "2016-07-22",
        "status": "A",
        "authorized_official_last_name": "WAGNER",
        "authorized_official_first_name": "TOMMY",
        "authorized_official_middle_name": "W",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "870-561-3300",
        "authorized_official_name_suffix": "Jr.",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Family Medicine",
            "state": "AR",
            "license": "E3873",
            "primary": true
        },
        {
            "code": "363LF0000X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Nurse Practitioner, Family",
            "state": "AR",
            "license": "A01771",
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "156106001",
            "state": "AR"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "WAGNER MEDICAL CLINIC",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Manila, AR

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 22, 2016; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • 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.