Philip Wagenbach, PA-C
Individual provider Active NPI Medical Physician Assistant · Bomoseen, VT
NPI 1790797116 · NPPES record last updated Oct 5, 2015
Key facts
- NPI
- 1790797116
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Medical Physician Assistant 363AM0700X
- License
- 055-0031268 (VT)
- Practice address
- 275 Route 30 N
Bomoseen, VT 05732-9647 - Phone
- (802) 468-5641
- Fax
- (802) 468-2923
- NPI assigned
- Aug 13, 2006
- Sex
- Male
- Sole proprietor
- No
Organizations & group practices 9
Hospital & facility affiliations 1
Medicare Care Compare profile
- Specialty
- Physician Assistant
- Education
- Other, 2005
- Medicare assignment
- Accepts the Medicare-approved amount as payment in full
- Group practices
- Community Health Centers of the Rutland Region Inc
Practice addresses (Care Compare)
215 Stratton Rd
Rutland, VT 05701-4621
Phone (802) 773-3386
275 Route 30 N
Bomoseen, VT 05732-9647
Phone (802) 468-5641
Hospital & facility affiliations
- Rutland Regional Medical Center
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in VT
- Eligible to order & refer
- Part B services: Yes · DME: Yes · Home health: Yes · Power mobility devices: Yes · Hospice: No
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20151119000526 | VT | Practitioner - Physician Assistant | 0446271845 | Reassigns benefits to 1 organization |
National Provider Directory
- Medicare enrollment (NPD)
- Yes
- Credentials
- Physician Assistant
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 001695 | CT | MD | Physician Assistant |
| 055-0031268 | VT | MD | Medical Physician Assistant |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Community Health Centers of the Rutland Region Inc | Current |
Accepting new patients | |
| Community Health Centers of the Rutland Region, Inc. | Past | Accepting new patients |
Locations
275 VT 30 N
Bomoseen, VT 05732
Phone (802) 468-5641
71 Allen St
Ste 402
Rutland, VT 05701
Phone (800) 468-9118
278 Vt Route 149
West Pawlet, VT 05775
Phone (800) 468-9118
Interoperability endpoints
- pwagenbach@chcrr.medentdirect.com
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Physician Assistant | 363A00000X | 001695 | CT | |
| Medical Physician Assistant | 363AM0700X | 055-0031268 | VT | Yes |
Addresses
Primary practice location
275 Route 30 N
Bomoseen, VT 05732-9647
Mailing address
700 School St
Pawtucket, RI 02860-5747
Phone (401) 616-2000
Other providers in Bomoseen, VT
All providers in Bomoseen, VT · Medical Physician Assistant in Vermont
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Oct 5, 2015. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Order and Referring (CMS).
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.