| Doctor Name: | MR. KEVIN MATTHEW WAGNER |
| NPI Number: | 1295735926 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | MD PT CERT MDT |
| License Number: | 115026 |
| Business Practice Address: | 11903 Saint Charles Rock Rd Bridgeton, MO - 630442623 |
| Business Phone Number: | 3147700900 |
| Business Fax Number: | 3147701673 |
| Mailing Address: | Back Pain Institute Of St. Louis Llc, 11903 St. Charles Rock Rd. BRIDGETON |
| State: | MO |
| Postal Code: | 63044 |
| Phone Number: | 3147700900 |
| Fax Number: | 3147398569 |
| NPI Enumeration Date: | 07/22/2005 |
| NPI Last Update Date: | 04/29/2010 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 225100000X |
| License Number: | 115026 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | MO |
| Taxonomy Type: | Respiratory, Developmental, Rehabilitative and Restorative Service Providers |
| Taxonomy Classification: | Physical Therapist |
| Taxonomy Specialization: | |
| Taxonomy Definition: | (1) Physical therapists are health care professionals who evaluate and treat people with health problems resulting from injury or disease. PT |