Basic Information
| Provider Information | |||||||||
| NPI: | 1063470649 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WAGMEISTER | ||||||||
| FirstName: | LEE | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4015 GATEWAY BLVD STE 2120 | ||||||||
| Address2: | |||||||||
| City: | NEWBURGH | ||||||||
| State: | IN | ||||||||
| PostalCode: | 476308925 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8124925457 | ||||||||
| FaxNumber: | 8124644485 | ||||||||
| Practice Location | |||||||||
| Address1: | 4015 GATEWAY BLVD | ||||||||
| Address2: | SUITE 2120 | ||||||||
| City: | NEWBURGH | ||||||||
| State: | IN | ||||||||
| PostalCode: | 476308925 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8128420907 | ||||||||
| FaxNumber: | 8124640536 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2006 | ||||||||
| LastUpdateDate: | 05/17/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208G00000X | 01052501A | IN | Y | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) | 208G00000X | 36924 | KY | N | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) |
ID Information
| ID | Type | State | Issuer | Description | 64024532 | 05 | KY | MEDICAID | 438544 | 01 | HEALTHLINK | OTHER | 200267590 | 05 | IN | MEDICAID | 000000174053 | 01 | ANTHEM | OTHER | 0000475621-01 | 01 | WELBORN HEALTH PLANS | OTHER | 330005278 | 01 | IN RR MCR | OTHER | 832011P | 01 | SIHO | OTHER |