Provider Demographics
NPI:1134140148
Name:WALLACE C BAKER
Entity Type:Organization
Organization Name:WALLACE C BAKER
Other - Org Name:BAKER FAMILY PRACTICE
Other - Org Type:Other Name
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:WALLACE
Authorized Official - Middle Name:C
Authorized Official - Last Name:BAKER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-524-6633
Mailing Address - Street 1:1880 JOHN ADAMS PKWY
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83401-4315
Mailing Address - Country:US
Mailing Address - Phone:208-524-6633
Mailing Address - Fax:208-524-9952
Practice Address - Street 1:1880 JOHN ADAMS PKWY
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83401-4315
Practice Address - Country:US
Practice Address - Phone:208-524-6633
Practice Address - Fax:208-524-9952
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-22
Last Update Date:2010-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM6919207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1083696967OtherIND NPI NUMBER
ID807937700Medicaid
IDD1614OtherRAILROAD MCR GROUP
ID8K123OtherGRP BLUECROSS NO.
ID000010027582OtherBLUE SHIELD GROUP NUMBER
ID72132OtherBLUECROSS NUMBER
ID000010001770OtherBLUE SHILD INDIVIDUAL
ID000010027582OtherBLUE SHIELD GROUP NUMBER
ID1083696967OtherIND NPI NUMBER
ID807937700Medicaid