1760043822 NPI number — DR. RUSSELL BARRE BAKER

Table of content: DR. RUSSELL BARRE BAKER (NPI 1760043822)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760043822 NPI number — DR. RUSSELL BARRE BAKER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BAKER
Provider First Name:
RUSSELL
Provider Middle Name:
BARRE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
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:
1760043822
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/08/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 909
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOUISVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40201-0909
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-588-0328
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
309 11TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CARROLLTON
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
41008-1435
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-732-3280
Provider Business Practice Location Address Fax Number:
502-732-3284
Provider Enumeration Date:
06/27/2019

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: 213E00000X , with the licence number:  247793 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 213ES0103X , with the licence number: 247793 , 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: 7100919580 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 300084017 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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