Basic Information
| Provider Information | |||||||||
| NPI: | 1871556084 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BAKER | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 812 GORMAN AVE | ||||||||
| Address2: | |||||||||
| City: | ELKINS | ||||||||
| State: | WV | ||||||||
| PostalCode: | 262413181 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3044315168 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 114 UNDERCLIFF TER | ||||||||
| Address2: | |||||||||
| City: | PRINCETON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 247402174 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3044250025 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2006 | ||||||||
| LastUpdateDate: | 03/03/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 28822 | SC | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207V00000X | 39390 | NC | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207V00000X | 28597 | WV | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 28822 | 01 | SC | SC LICENSE | OTHER | N39390 | 05 | SC | MEDICAID | SC34823365 | 01 | SC | MEDICARE PIN | OTHER | 39390 | 01 | NC | NC LICENSE | OTHER |