Provider Demographics
NPI:1801975420
Name:BAILEY, CHARLENE (PA C)
Entity type:Individual
Prefix:MS
First Name:CHARLENE
Middle Name:
Last Name:BAILEY
Suffix:
Gender:F
Credentials:PA C
Other - Prefix:
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Mailing Address - Street 1:15501 METROPOLITAN PKWY
Mailing Address - Street 2:STE110
Mailing Address - City:CLINTON TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48036-1684
Mailing Address - Country:US
Mailing Address - Phone:586-286-9720
Mailing Address - Fax:586-286-3134
Practice Address - Street 1:15501 METROPOLITAN PKWY
Practice Address - Street 2:STE110
Practice Address - City:CLINTON TWP
Practice Address - State:MI
Practice Address - Zip Code:48036-1684
Practice Address - Country:US
Practice Address - Phone:586-286-9720
Practice Address - Fax:586-286-3134
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-03
Last Update Date:2009-02-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5601002587363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI550140OtherBLUE CROSS BLUE SHIELD
MI352206784OtherTAX ID NUMBER
MIQ30454Medicare UPIN
MI0P04100001Medicare PIN