Basic Information
| Provider Information | |||||||||
| NPI: | 1952530594 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BAKER | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | DOUGLAS | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1 LECOM PL | ||||||||
| Address2: | |||||||||
| City: | ERIE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 165052571 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | |||||||||
| FaxNumber: | 8148682522 | ||||||||
| Practice Location | |||||||||
| Address1: | 2000 W GRANDVIEW BLVD | ||||||||
| Address2: | |||||||||
| City: | ERIE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 165091029 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8148681088 | ||||||||
| FaxNumber: | 8148681094 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/02/2009 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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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 | 207Q00000X | OS006249L | PA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0010935600010 | 05 | PA | MEDICAID | 0010935600007 | 05 | PA | MEDICAID | 0010935600013 | 05 | PA | MEDICAID | 0010935600016 | 05 | PA | MEDICAID | 0010935600006 | 05 | PA | MEDICAID | 0010935600012 | 05 | PA | MEDICAID | 0010935600015 | 05 | PA | MEDICAID | 0010935600008 | 05 | PA | MEDICAID | 0010935600009 | 05 | PA | MEDICAID | 0010935600011 | 05 | PA | MEDICAID | 0010935600014 | 05 | PA | MEDICAID |