Basic Information
Provider Information | |||||||||
NPI: | 1710913512 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BAKER | ||||||||
FirstName: | RONALD | ||||||||
MiddleName: | P | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 5515 CLEVELAND AVE | ||||||||
Address2: |   | ||||||||
City: | STEVENSVILLE | ||||||||
State: | MI | ||||||||
PostalCode: | 491279670 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2694299644 | ||||||||
FaxNumber: | 2694294002 | ||||||||
Practice Location | |||||||||
Address1: | 5515 CLEVELAND AVE | ||||||||
Address2: |   | ||||||||
City: | STEVENSVILLE | ||||||||
State: | MI | ||||||||
PostalCode: | 491279670 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2694299644 | ||||||||
FaxNumber: | 2694294002 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/23/2006 | ||||||||
LastUpdateDate: | 11/03/2015 | ||||||||
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 | 207Q00000X | 4301032453 | MI | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 80058899 | 01 |   | RAILROAD MEDICARE | OTHER | 0801106811 | 01 | MI | BLUE CROSS | OTHER | 2893871 | 05 | MI |   | MEDICAID | AB1398735 | 01 | MI | DEA | OTHER | 1013388 | 01 |   | CIGNA | OTHER | 01-31132 | 01 | MI | PHP | OTHER |