Provider Demographics
NPI:1477592335
Name:BAE, CHARLES J (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:J
Last Name:BAE
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 1:3624 MARKET ST
Mailing Address - Street 2:STE 201
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104-2614
Mailing Address - Country:US
Mailing Address - Phone:215-662-7772
Mailing Address - Fax:
Practice Address - Street 1:3624 MARKET ST STE 201
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-2614
Practice Address - Country:US
Practice Address - Phone:215-662-7772
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD4615842084S0012X, 2084N0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0600XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyClinical Neurophysiology
No2084S0012XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologySleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2372847Medicaid
OH130026373OtherMEDICARE RAILROAD
OHBA7343831Medicare PIN
OH130026373OtherMEDICARE RAILROAD