NPIMap

Individual provider Active NPI

Richard W Wagoner, M.D.

  • Internal Medicine Physician
  • Havana, IL
National Provider Identifier
1861458952
Registry record updated Jun 1, 2012
On this page

Key facts

NPPES NPI Registry
Primary specialty
Internal Medicine PhysicianTaxonomy code 207R00000X
License
036104579 Issued in IL
Practice address
615 N Promenade St
Havana, IL 62644-1243
Phone
(309) 543-6600
Fax
(309) 543-2089
NPI assigned
Apr 26, 2006
Last updated
Jun 1, 2012By the provider in NPPES
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Jun 1, 2012

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

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Internal Medicine Physician 207R00000X 036104579 IL Primary

Addresses

Primary practice location

615 N Promenade St
Havana, IL 62644-1243

Mailing address

615 N Promenade St
P O Box 530
Havana, IL 62644-1015
Phone (309) 543-6600

Other identifiers 1

IdentifierTypeStateIssuer
036104579MedicaidIL

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
I20100507000571 IL Practitioner - Internal MedicinePractitioner - Pediatric Medicine 7416085675 Reassigns benefits to 1 organization

Care Compare profile

Medicare Care Compare
Specialty
Internal MedicineAlso: Pediatric Medicine
Education
Other, 2001
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices
Mason Hospital DistrictGroup PAC ID 2466360607, 41 clinicians

Practice addresses (Care Compare)

615 N Promenade St
Havana, IL 62644-1243
Phone (309) 543-8510

Hospital & facility affiliations

Merit-based Incentive Payment System (MIPS)

Final score
91.05 of 100Reported as apm
Quality
72.1
Promoting interoperability
100
Improvement activities
40

Procedures performed for Medicare patients

ProcedureNumber of procedures
Removal of skin lesions1-10

National Provider Directory

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

Practice roles

OrganizationSpecialtyStatusNew patients
Mason Hospital District CurrentSince Jul 30, 2001 Accepting new patients
Mason Hospital District CurrentSince Jul 30, 2001 Accepting new patients
Mason Hospital District Past Accepting new patients

Locations

615 N Promenade St
Havana, IL 62644
Phone (309) 543-8510

Interoperability endpoints

  • Direct secure messaging: richard.wagoner@hmamdh.eclinicaldirectplus.com

Organizations & group practices 3

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

Hospital & facility affiliations 5

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

NPI Registry JSON

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

{
    "created_epoch": "1146009600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1338508800000",
    "number": "1861458952",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "615 N PROMENADE ST",
            "address_2": "P O BOX 530",
            "city": "HAVANA",
            "state": "IL",
            "postal_code": "626441015",
            "telephone_number": "309-543-6600",
            "fax_number": "309-543-2089"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "615 N PROMENADE ST",
            "city": "HAVANA",
            "state": "IL",
            "postal_code": "626441243",
            "telephone_number": "309-543-6600",
            "fax_number": "309-543-2089"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WAGONER",
        "first_name": "RICHARD",
        "middle_name": "W",
        "credential": "M.D.",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2006-04-26",
        "last_updated": "2012-06-01",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207R00000X",
            "taxonomy_group": "",
            "desc": "Internal Medicine",
            "state": "IL",
            "license": "036104579",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "036104579",
            "state": "IL"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Havana, IL

Sources for this page

Verify at the official NPI Registry.