1336185339 NPI number — EWA B BAK M.D.

Table of content: EWA B BAK M.D. (NPI 1336185339)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336185339 NPI number — EWA B BAK M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BAK
Provider First Name:
EWA
Provider Middle Name:
B
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1336185339
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/16/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1611 S GREEN RD STE 260
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTH EUCLID
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44121-4192
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
216-297-2059
Provider Business Mailing Address Fax Number:
216-297-2066

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1611 S GREEN RD STE 260
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLEVELAND
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44121-4192
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
216-297-2059
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  36870 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 000000216081 . This is a "BLUE CROSS & BLUE SHIELD" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 022092900 . This is a "BLACK LUNG INSURANCE" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 7140400 . This is a "AETNA INSURANCE COMPANY" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 1283881 . This is a "UNITED MINE WORKERS ASSOC" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 64046006 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 110231108 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".




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