Basic Information
Provider Information | |||||||||
NPI: | 1457464786 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BAKER | ||||||||
FirstName: | KENNETH | ||||||||
MiddleName: | E | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 333 CEDAR ST | ||||||||
Address2: |   | ||||||||
City: | NEW HAVEN | ||||||||
State: | CT | ||||||||
PostalCode: | 065103206 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2037855253 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 333 CEDAR ST | ||||||||
Address2: |   | ||||||||
City: | NEW HAVEN | ||||||||
State: | CT | ||||||||
PostalCode: | 065103206 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2037855253 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/17/2006 | ||||||||
LastUpdateDate: | 07/17/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | MD11832 | RI | Y |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
ID | Type | State | Issuer | Description | 1198-5 | 01 | RI | BCBS OFFICE TGR | OTHER | 2203 | 01 | RI | NHP TGR | OTHER | 494201 | 01 | RI | TUFTS TGR | OTHER | 7417697 | 01 | RI | AETNA OFFICE TGR | OTHER | 16-00137 | 01 | RI | UHC TGR | OTHER | 412652 | 01 | RI | BLUE CHIP TGR | OTHER | 7057871 | 05 | RI |   | MEDICAID | P00272151 | 01 | RI | RR MEDICARE TGR | OTHER | 1570-5 | 01 | RI | BCBS KENT TGR | OTHER | 50356624 | 01 | RI | UNICARE LIFE & HLTH TGR | OTHER | 756624 | 01 | RI | CONNECTICARE INC TGR | OTHER | AA42348 | 01 | RI | HARVARD PILGRIM TGR | OTHER |