Basic Information
| Provider Information | |||||||||
| NPI: | 1922088228 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BAGENSTOSE | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 801 MEDICAL DR | ||||||||
| Address2: | SUITE A | ||||||||
| City: | LIMA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458044099 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192226622 | ||||||||
| FaxNumber: | 4192240015 | ||||||||
| Practice Location | |||||||||
| Address1: | 801 MEDICAL DR | ||||||||
| Address2: | SUITE A | ||||||||
| City: | LIMA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458044099 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192226622 | ||||||||
| FaxNumber: | 4192240015 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/20/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 207X00000X | 35034777-B | OH | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 0427452 | 05 | OH | MEDICAID | 000000021073 | 01 | OH | ANTHEM | OTHER |