Basic Information
| Provider Information | |||||||||
| NPI: | 1215935739 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BAKER | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | RONALD | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DPM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1660 FEEHANVILLE DR STE 450 | ||||||||
| Address2: | |||||||||
| City: | MOUNT PROSPECT | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600566023 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8473907666 | ||||||||
| FaxNumber: | 8473909345 | ||||||||
| Practice Location | |||||||||
| Address1: | 939 W NORTH AVE STE 610 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606427138 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8473907666 | ||||||||
| FaxNumber: | 8473909345 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2005 | ||||||||
| LastUpdateDate: | 12/17/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | 016-005146 | IL | N | Podiatric Medicine & Surgery Service Providers | Podiatrist | 213ES0103X | 016-005146 | IL | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
ID Information
| ID | Type | State | Issuer | Description | 016005146 | 05 | IL | MEDICAID | 60000380 | 01 | IL | BCBS | OTHER |