Provider Demographics
NPI:1093870073
Name:BAE, JEAN S (MD)
Entity Type:Individual
Prefix:
First Name:JEAN
Middle Name:S
Last Name:BAE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 RAY O VAC DR
Mailing Address - Street 2:SUITE 220
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53711-2479
Mailing Address - Country:US
Mailing Address - Phone:608-276-9191
Mailing Address - Fax:608-276-9144
Practice Address - Street 1:700 RAY O VAC DR
Practice Address - Street 2:SUITE 220
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53711-2479
Practice Address - Country:US
Practice Address - Phone:608-276-9191
Practice Address - Fax:608-276-9144
Is Sole Proprietor?:No
Enumeration Date:2006-12-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI40078-0202084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34136400Medicaid
H47828Medicare UPIN
WI34136400Medicaid