1629274956 NPI number — DR. GLENN BAKER CHARLTON M.D.

Table of content: JOSEPH JAHNER (NPI 1609464692)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629274956 NPI number — DR. GLENN BAKER CHARLTON M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CHARLTON
Provider First Name:
GLENN
Provider Middle Name:
BAKER
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1629274956
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/15/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2418 JILLIAN LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HERMITAGE
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
16148-7728
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-724-9539
Provider Business Mailing Address Fax Number:
724-591-8909

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2962 E STATE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HERMITAGE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
16148-2757
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
724-777-1895
Provider Business Practice Location Address Fax Number:
724-591-8909
Provider Enumeration Date:
06/24/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207P00000X , with the licence number:  200701478 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207P00000X , with the licence number: M5097 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207P00000X , with the licence number: MD019961E , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: MD019961E , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 146GA . This is a "BCBS OF NC" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 5907696 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000549072 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".