Basic Information
| Provider Information | |||||||||
| NPI: | 1538273859 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BAKER | ||||||||
| FirstName: | SHANE | ||||||||
| MiddleName: | ARTHUR | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 629 | ||||||||
| Address2: | |||||||||
| City: | OGDEN | ||||||||
| State: | UT | ||||||||
| PostalCode: | 844020629 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8016216671 | ||||||||
| FaxNumber: | 8016276679 | ||||||||
| Practice Location | |||||||||
| Address1: | 1303 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | CEDAR CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 84721 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4358685000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/17/2006 | ||||||||
| LastUpdateDate: | 07/16/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 308374-1205 | UT | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 01051615A | IN | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 200132910 | 05 | IN | MEDICAID |