Provider Demographics
NPI:1164624508
Name:BAUMGARTNER, LYSLE (MD)
Entity Type:Individual
Prefix:
First Name:LYSLE
Middle Name:
Last Name:BAUMGARTNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:RICHARD
Other - Middle Name:
Other - Last Name:BAUMGARTNER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:3400 KENNY RD
Mailing Address - Street 2:
Mailing Address - City:UPPER ARLINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:43221-1500
Mailing Address - Country:US
Mailing Address - Phone:614-457-8158
Mailing Address - Fax:614-457-9155
Practice Address - Street 1:3400 KENNY RD
Practice Address - Street 2:
Practice Address - City:UPPER ARLINGTON
Practice Address - State:OH
Practice Address - Zip Code:43221-1500
Practice Address - Country:US
Practice Address - Phone:614-457-8158
Practice Address - Fax:614-457-9155
Is Sole Proprietor?:No
Enumeration Date:2007-06-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-0229542084P0015X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0015XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychosomatic Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0449385Medicaid
OH0449385Medicaid