Provider Demographics
NPI:1205135670
Name:BAI, PENG (DO)
Entity type:Individual
Prefix:
First Name:PENG
Middle Name:
Last Name:BAI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4601 PARK RD STE 300
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28209-2290
Mailing Address - Country:US
Mailing Address - Phone:704-323-2000
Mailing Address - Fax:
Practice Address - Street 1:180 KIMEL PARK DR
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-6976
Practice Address - Country:US
Practice Address - Phone:704-323-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-23
Last Update Date:2018-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2015-00426208100000X, 208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1205135670Medicaid
NC1205135670Medicaid
NCNCN091AMedicare PIN