NPIMap

Individual provider Active NPI

Paul A Wagner, DO

  • Family Medicine Physician
  • Hart, MI
National Provider Identifier
1962434043
Registry record updated Aug 29, 2011
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
License
5101011554 Issued in MI
Practice address
611 East Main St
Hart, MI 49420-1190
Phone
(231) 873-5675
Fax
(231) 873-1825
NPI assigned
Jul 7, 2006
Last updated
Aug 29, 2011By the provider in NPPES
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Aug 29, 2011

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

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine Physician 207Q00000X PW011554 MI
Family Medicine Physician 207Q00000X 5101011554 MI Primary

Addresses

Primary practice location

611 East Main St
Hart, MI 49420-1190

Mailing address

611 East Main Street
Hart, MI 49420-1190
Phone (231) 873-5675

Other identifiers 6

IdentifierTypeStateIssuer
3015197MedicaidMI
3015197 TYPE 11MedicaidMI
080058226OtherMIMEDICARE RAILROAD
010F476090OtherMIBCBS
0F40011OtherMIBCBSMI
5641515OtherMIBCBS PIN NUMBER

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MI
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
I20040715000453 MI Practitioner - Emergency MedicinePractitioner - General Practice 7911986948 Reassigns benefits to 1 organization

Care Compare profile

Medicare Care Compare
Specialty
Emergency Medicine
Education
Ohio University, College of Osteopathic Medicine, 1985
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices
Mercy Health PartnersGroup PAC ID 1456430016, 65 clinicians

Practice addresses (Care Compare)

611 E Main St
Hart, MI 49420-1190
Phone (231) 873-5675

71 Bevier St
Shelby, MI 49455-1209
Phone (231) 861-2187

Hospital & facility affiliations

Procedures performed for Medicare patients

ProcedureNumber of procedures
Melanoma (skin cancer) excision1-10

National Provider Directory

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

State licenses

LicenseStateTypeSpecialty
5101011554MIMDFamily Medicine Physician
PW011554MIMDFamily Medicine Physician

Practice roles

OrganizationSpecialtyStatusNew patients
Mercy Health Partners Family Medicine CurrentSince Mar 1, 2014 Accepting new patients
Mercy Health Partners CurrentSince Mar 1, 2014 Accepting new patients
Lakeshore Emergency Solutions, PLLC Past Accepting new patients
Mercy Health Partners Past Accepting new patients
Mercy Urgent Care Family Medicine Past Accepting new patients

Locations

611 E Main St
Hart, MI 49420
Phone (231) 873-5478

1700 Oak Ave
Muskegon, MI 49442
Phone (231) 672-6430

71 Bevier St
Shelby, MI 49455
Phone (231) 861-2172

72 S State St
Shelby, MI 49455
Phone (231) 728-4601

Organizations & group practices 5

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 6

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": "1152230400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1314576000000",
    "number": "1962434043",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "611 EAST MAIN STREET",
            "city": "HART",
            "state": "MI",
            "postal_code": "494201190",
            "telephone_number": "231-873-5675",
            "fax_number": "231-873-1825"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "611 EAST MAIN ST",
            "city": "HART",
            "state": "MI",
            "postal_code": "494201190",
            "telephone_number": "231-873-5675",
            "fax_number": "231-873-1825"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WAGNER",
        "first_name": "PAUL",
        "middle_name": "A",
        "credential": "DO",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2006-07-07",
        "last_updated": "2011-08-29",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "MI",
            "license": "PW011554",
            "primary": false
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "MI",
            "license": "5101011554",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "3015197",
            "state": "MI"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "3015197 TYPE 11",
            "state": "MI"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICARE RAILROAD",
            "identifier": "080058226",
            "state": "MI"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BCBS",
            "identifier": "010F476090",
            "state": "MI"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BCBSMI",
            "identifier": "0F40011",
            "state": "MI"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BCBS PIN NUMBER",
            "identifier": "5641515",
            "state": "MI"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Hart, MI

Sources for this page

Verify at the official NPI Registry.