1659386076 NPI number — MATTHEW J BAK M.D.

Table of content: MATTHEW J BAK M.D. (NPI 1659386076)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659386076 NPI number — MATTHEW J BAK M.D.

Organization/Personal Information

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

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:
1659386076
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/28/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 936
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORFOLK
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23501-0936
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
757-388-6200
Provider Business Mailing Address Fax Number:
757-388-6201

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
600 GRESHAM DR
Provider Second Line Business Practice Location Address:
SUITE 1100
Provider Business Practice Location Address City Name:
NORFOLK
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23507-1904
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
757-388-6200
Provider Business Practice Location Address Fax Number:
757-388-6201
Provider Enumeration Date:
07/31/2006

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: 207YX0007X , with the licence number:  0101245661 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: -004 . This is a "TRICARE/CHAMPUS" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: PAR . This is a "AETNA" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: PAR . This is a "VIRGINIA HEALTH NETWORK" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 373343 . This is a "ANTHEM BC/BS (FIRST COLONIAL RD.)" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: PAR . This is a "CIGNA" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: PAR . This is a "CORVEL/CORCARE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 10047408 . This is a "SENTARA OPTIMA HEALTH" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 1659386076 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: PAR . This is a "USA MANAGED CARE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: PAR . This is a "VIRGINIA PREMIER HEALTH" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: PAR . This is a "MULTIPLAN" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 11764 . This is a "BC/BS" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: PAR . This is a "UNITED HEALTH CARE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 373342 . This is a "ANTHEM BC/BS (GRESHAM DR.)" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: PAR . This is a "FIRST HEALTH COMMERCIAL/SOUTHERN HEALTH/COVENTRY" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 5911764 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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