Provider Demographics
NPI:1508047226
Name:KEVIN BAXTER DO PC
Entity Type:Organization
Organization Name:KEVIN BAXTER DO PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CORPORATE SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:JACKILYN
Authorized Official - Middle Name:
Authorized Official - Last Name:BAXTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-741-3570
Mailing Address - Street 1:PO BOX 450
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:OR
Mailing Address - Zip Code:97103-0450
Mailing Address - Country:US
Mailing Address - Phone:503-741-3570
Mailing Address - Fax:503-741-3569
Practice Address - Street 1:10 PIER 1 STE 301
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:OR
Practice Address - Zip Code:97103-6338
Practice Address - Country:US
Practice Address - Phone:503-741-3570
Practice Address - Fax:503-741-3569
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-21
Last Update Date:2021-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADO24314207Q00000X
261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORH43280Medicare UPIN