Basic Information
| Provider Information | |||||||||
| NPI: | 1891797080 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BAKER | ||||||||
| FirstName: | KEITH | ||||||||
| MiddleName: | ANDREW | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 110 W. ENT AVE. | ||||||||
| Address2: | 21 MDOS/SGOF -FAMILY PRACTICE | ||||||||
| City: | PETERSON AFB | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809141540 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195562273 | ||||||||
| FaxNumber: | 7195661226 | ||||||||
| Practice Location | |||||||||
| Address1: | 559 VINCENT ST | ||||||||
| Address2: | 21 MDOS/SGOF -FAM HLTH | ||||||||
| City: | PETERSON AFB | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809141540 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195562273 | ||||||||
| FaxNumber: | 7195561226 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2005 | ||||||||
| LastUpdateDate: | 09/24/2014 | ||||||||
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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 | 207Q00000X | 26315 | CO | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 01263151 | 05 | CO | MEDICAID |