Provider Demographics
NPI:1972914935
Name:LIM, CHARLES (PA-C)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:LIM
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 N CAROLINE ST
Mailing Address - Street 2:SUITE 5214
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21287-0006
Mailing Address - Country:US
Mailing Address - Phone:917-705-3034
Mailing Address - Fax:
Practice Address - Street 1:601 N CAROLINE ST
Practice Address - Street 2:SUITE 5214
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21287-0006
Practice Address - Country:US
Practice Address - Phone:410-955-1830
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-13
Last Update Date:2014-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA056843363A00000X
NJ25MP00335400363A00000X
MDC05403363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant