Provider Demographics
NPI:1336219526
Name:BAE, SUNG HWAN (DPT)
Entity Type:Individual
Prefix:
First Name:SUNG
Middle Name:HWAN
Last Name:BAE
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6263 POPLAR AVE
Mailing Address - Street 2:STE 801
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38119-4701
Mailing Address - Country:US
Mailing Address - Phone:901-685-7227
Mailing Address - Fax:267-321-2079
Practice Address - Street 1:11601 WILSHIRE BLVD
Practice Address - Street 2:STE 105
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-0509
Practice Address - Country:US
Practice Address - Phone:310-665-7100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2009-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA32148OtherLICENSE#
CAWPT32148AMedicare PIN
CAW17215CMedicare PIN