Provider Demographics
NPI:1558704791
Name:BAE, CONEY (MD)
Entity Type:Individual
Prefix:
First Name:CONEY
Middle Name:
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 1:1600 VERNON RD STE A
Mailing Address - Street 2:
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30240-4143
Mailing Address - Country:US
Mailing Address - Phone:706-880-4143
Mailing Address - Fax:706-880-7343
Practice Address - Street 1:1600 VERNON RD STE A
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30240-4143
Practice Address - Country:US
Practice Address - Phone:706-880-4143
Practice Address - Fax:706-880-7343
Is Sole Proprietor?:No
Enumeration Date:2013-04-08
Last Update Date:2021-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA89209208600000X
FLME133865208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL100073600Medicaid