Provider Demographics
NPI:1104867480
Name:BAKER, RANDAL (MD)
Entity Type:Individual
Prefix:
First Name:RANDAL
Middle Name:
Last Name:BAKER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2060 E PARIS AVE SE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-6113
Mailing Address - Country:US
Mailing Address - Phone:616-956-6657
Mailing Address - Fax:616-956-6637
Practice Address - Street 1:2060 E PARIS AVE SE
Practice Address - Street 2:SUITE 100
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-6113
Practice Address - Country:US
Practice Address - Phone:616-956-6100
Practice Address - Fax:616-956-6637
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2013-06-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301057752208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1256001Medicare PIN
G52495Medicare UPIN