Provider Demographics
NPI:1073091138
Name:BAKER, MAX JOSEPH
Entity Type:Individual
Prefix:
First Name:MAX
Middle Name:JOSEPH
Last Name:BAKER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5571 PARVIEW DR APT 301
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48346-2833
Mailing Address - Country:US
Mailing Address - Phone:248-202-8316
Mailing Address - Fax:
Practice Address - Street 1:9381 AUTUMNGLO DR
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:MI
Practice Address - Zip Code:48348-1611
Practice Address - Country:US
Practice Address - Phone:248-202-8316
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-01
Last Update Date:2018-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
171M00000XOtherTAXONOMY