Provider Demographics
NPI:1861466005
Name:BAUMGARTNER, CHARLENE M (PA)
Entity Type:Individual
Prefix:
First Name:CHARLENE
Middle Name:M
Last Name:BAUMGARTNER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 MEDICAL PARK DR
Mailing Address - Street 2:
Mailing Address - City:WATERVLIET
Mailing Address - State:MI
Mailing Address - Zip Code:49098-9225
Mailing Address - Country:US
Mailing Address - Phone:269-463-3600
Mailing Address - Fax:
Practice Address - Street 1:400 MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:WATERVLIET
Practice Address - State:MI
Practice Address - Zip Code:49098-9225
Practice Address - Country:US
Practice Address - Phone:269-463-3600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2015-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601003338363AM0700X
MICB003338363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1861466005Medicaid