Provider Demographics
NPI:1063470649
Name:WAGMEISTER, LEE S (MD)
Entity Type:Individual
Prefix:DR
First Name:LEE
Middle Name:S
Last Name:WAGMEISTER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4015 GATEWAY BLVD STE 2120
Mailing Address - Street 2:
Mailing Address - City:NEWBURGH
Mailing Address - State:IN
Mailing Address - Zip Code:47630-8925
Mailing Address - Country:US
Mailing Address - Phone:812-492-5457
Mailing Address - Fax:812-464-4485
Practice Address - Street 1:4015 GATEWAY BLVD
Practice Address - Street 2:SUITE 2120
Practice Address - City:NEWBURGH
Practice Address - State:IN
Practice Address - Zip Code:47630-8925
Practice Address - Country:US
Practice Address - Phone:812-842-0907
Practice Address - Fax:812-464-0536
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2016-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01052501A208G00000X
KY36924208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64024532Medicaid
438544OtherHEALTHLINK
IN200267590Medicaid
000000174053OtherANTHEM
0000475621-01OtherWELBORN HEALTH PLANS
330005278OtherIN RR MCR
832011POtherSIHO
832011POtherSIHO
KY64024532Medicaid
000000174053OtherANTHEM