Provider Demographics
NPI:1184669848
Name:BAESE, PHILIP LUKE (MD)
Entity type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:LUKE
Last Name:BAESE
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 1:501 CHIPETA WAY
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84108-1222
Mailing Address - Country:US
Mailing Address - Phone:801-587-3102
Mailing Address - Fax:
Practice Address - Street 1:650 KOMAS DR
Practice Address - Street 2:200
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84108-1229
Practice Address - Country:US
Practice Address - Phone:801-581-5515
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-18
Last Update Date:2021-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT363340-12052084P0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0005XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurodevelopmental Disabilities