Provider Demographics
NPI:1417922758
Name:BAKER, ETHELBERT JACKSON (MD)
Entity Type:Individual
Prefix:
First Name:ETHELBERT
Middle Name:JACKSON
Last Name:BAKER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:272 HOSPITAL RD STE 6
Mailing Address - Street 2:
Mailing Address - City:CHILLICOTHE
Mailing Address - State:OH
Mailing Address - Zip Code:45601-9031
Mailing Address - Country:US
Mailing Address - Phone:740-779-4222
Mailing Address - Fax:740-779-4257
Practice Address - Street 1:4439 STATE ROUTE 159
Practice Address - Street 2:SUITE 130
Practice Address - City:CHILLICOTHE
Practice Address - State:OH
Practice Address - Zip Code:45601-8207
Practice Address - Country:US
Practice Address - Phone:740-779-4360
Practice Address - Fax:740-779-4369
Is Sole Proprietor?:No
Enumeration Date:2006-02-21
Last Update Date:2023-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK9019208G00000X
OH35068644208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0159260Medicaid
OH0159260Medicaid