Provider Demographics
NPI:1265694376
Name:LOIS WAGSTROM M.D., P.C.
Entity type:Organization
Organization Name:LOIS WAGSTROM M.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LOIS
Authorized Official - Middle Name:
Authorized Official - Last Name:WAGSTROM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:615-329-1822
Mailing Address - Street 1:250 25TH AVE N
Mailing Address - Street 2:SUITE 301
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37203-1632
Mailing Address - Country:US
Mailing Address - Phone:615-329-1822
Mailing Address - Fax:615-327-3206
Practice Address - Street 1:250 25TH AVE N
Practice Address - Street 2:SUITE 301
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37203-1632
Practice Address - Country:US
Practice Address - Phone:615-329-1822
Practice Address - Fax:615-327-3206
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-30
Last Update Date:2008-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMDO212522086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN30583582Medicare PIN