Provider Demographics
NPI:1023150919
Name:LAUREN E. WAGNER, M.D., S.C.
Entity type:Organization
Organization Name:LAUREN E. WAGNER, M.D., S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LAUREN
Authorized Official - Middle Name:E
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:312-255-8111
Mailing Address - Street 1:333 E ONTARIO ST
Mailing Address - Street 2:SUITE #3303B
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-4804
Mailing Address - Country:US
Mailing Address - Phone:312-255-8111
Mailing Address - Fax:
Practice Address - Street 1:333 E ONTARIO ST
Practice Address - Street 2:SUITE #3303B
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-4804
Practice Address - Country:US
Practice Address - Phone:312-255-8111
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty