Basic Information
| Provider Information | |||||||||
| NPI: | 1629048244 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LYSANDER | ||||||||
| FirstName: | VIMALESH | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 65274 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282650274 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8003778721 | ||||||||
| FaxNumber: | 3045232241 | ||||||||
| Practice Location | |||||||||
| Address1: | 1950 MOUNT SAINT MARYS DR | ||||||||
| Address2: | |||||||||
| City: | NELSONVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 457641280 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7407531931 | ||||||||
| FaxNumber: | 7407533177 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/25/2006 | ||||||||
| LastUpdateDate: | 05/08/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 35-06-2837-L | OH | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0893298 | 05 | OH | MEDICAID | 5619197341A48 | 01 | OH | BLUECROSS BLUESHIELD | OTHER |