Healthcare Provider Details

I. General information

NPI: 1295714590
Provider Name (Legal Business Name): MICHAEL J LYSTER IV D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/13/2006
Last Update Date: 01/07/2021
Certification Date: 01/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

703 TYLER ST SUITE 250
SANDUSKY OH
44870-3367
US

IV. Provider business mailing address

703 TYLER ST SUITE 250
SANDUSKY OH
44870-3367
US

V. Phone/Fax

Practice location:
  • Phone: 440-414-9300
  • Fax: 216-201-5588
Mailing address:
  • Phone: 440-414-9300
  • Fax: 216-201-5588

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number34005911
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: