NPIMap

Individual provider Active NPI

Tommy W Wagner, MD

  • Family Medicine Physician
  • Manila, AR
National Provider Identifier
1952385064
Registry record updated Feb 20, 2014
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
License
E3873 Issued in AR
Practice address
3644 W St Hwy 18
Manila, AR 72442
Phone
(870) 561-3300
Fax
(870) 561-3307
NPI assigned
Dec 1, 2005
Last updated
Feb 20, 2014By the provider in NPPES
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Feb 20, 2014

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

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine Physician 207Q00000X E3873 AR Primary

Addresses

Primary practice location

3644 W St Hwy 18
Manila, AR 72442

Mailing address

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

Other identifiers 1

IdentifierTypeStateIssuer
156106001MedicaidAR

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in AR
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
I20040513000982 AR Practitioner - Family Practice 2264422195 Reassigns benefits to 2 organizations

Care Compare profile

Medicare Care Compare
Specialty
Family Practice
Education
University of Arkansas College of Medicine, 2002
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices
T W Wagner IncGroup PAC ID 1153359096, 9 clinicians

Practice addresses (Care Compare)

3644 W Hwy 18
Wagner Medical Clinic
Manila, AR 72442
Phone (870) 561-3300

Hospital & facility affiliations

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
T W Wagner Inc Family Medicine CurrentSince Oct 6, 2003 Accepting new patients
T W Wagner Inc Family Medicine CurrentSince Jul 15, 2005 Accepting new patients
Riverside Medical Clinic Family Medicine CurrentSince Nov 15, 2010 Accepting new patients
Associated Healthcare Systems of Randolph County, Inc. Past Accepting new patients
Paragon Contracting Services LLC Past Accepting new patients
Acs Primary Care Physicians of Arkansas PA Past Accepting new patients
T W Wagner Inc Past Accepting new patients
Heritage Foot Clinic LLC Past Accepting new patients
T W Wagner Inc Past Accepting new patients

Locations

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

803 Highway 18
Lake City, AR 72437
Phone (870) 237-1055

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

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

3644 W State Highway 18
Manila, AR 72442
Phone (870) 561-1500

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

Ownership & related parties

All facility ownership & control disclosures 2

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
Wagner Medical ClinicManila, AR, CCN 043856 Rural health clinic 5% Or Greater Direct Ownership Interest
Corporate Director
W-2 Managing Employee		 Jul 15, 2005
Jul 15, 2005
Jul 15, 2005
Wagner Medical ClinicLepanto, AR, CCN 043961 Rural health clinic 5% Or Greater Direct Ownership Interest (100%)
Corporate Officer (100%)
W-2 Managing Employee (100%)		 Oct 6, 2003
Oct 6, 2003
Oct 6, 2003

Owned or controlled facilities with NPI records 2

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

  • T W Wagner Inc
    • Rural Health Clinic/Center
    • Lepanto, AR
    • NPI 1114734969

    5% Or Greater Direct Ownership Interest, Corporate Officer, W-2 Managing Employee

    CMS ownership
  • T W Wagner Inc
    • Rural Health Clinic/Center
    • Manila, AR
    • NPI 1548244171

    5% Or Greater Direct Ownership Interest, Corporate Director, W-2 Managing Employee

    CMS ownership

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, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

Hospital & facility affiliations 8

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": "1133395200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1392854400000",
    "number": "1952385064",
    "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": "72442",
            "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 ST HWY 18",
            "city": "MANILA",
            "state": "AR",
            "postal_code": "72442",
            "telephone_number": "870-561-3300",
            "fax_number": "870-561-3307"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WAGNER",
        "first_name": "TOMMY",
        "middle_name": "W",
        "credential": "MD",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2005-12-01",
        "last_updated": "2014-02-20",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "AR",
            "license": "E3873",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "156106001",
            "state": "AR"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Manila, AR

Sources for this page

Verify at the official NPI Registry.