Basic Information
| Provider Information | |||||||||
| NPI: | 1376802157 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BAKER | ||||||||
| FirstName: | PHILLIP | ||||||||
| MiddleName: | BRADFORD | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 222 MEDICAL CIR | ||||||||
| Address2: | |||||||||
| City: | MOREHEAD | ||||||||
| State: | KY | ||||||||
| PostalCode: | 403511179 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6067836500 | ||||||||
| FaxNumber: | 6067836878 | ||||||||
| Practice Location | |||||||||
| Address1: | 222 MEDICAL CIR | ||||||||
| Address2: | |||||||||
| City: | MOREHEAD | ||||||||
| State: | KY | ||||||||
| PostalCode: | 403511179 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6067836500 | ||||||||
| FaxNumber: | 6067836878 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/14/2012 | ||||||||
| LastUpdateDate: | 01/16/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/16/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | R2868 | KY | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 04048 | KY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | K218390 | 01 | KY | MEDICARE OWINGSVILLE | OTHER | 7100287680 | 05 | KY | MEDICAID |