Provider Demographics
NPI:1548234065
Name:BAER, PHYLLIS (MD)
Entity Type:Individual
Prefix:DR
First Name:PHYLLIS
Middle Name:
Last Name:BAER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1135 MORTON STREET
Mailing Address - Street 2:
Mailing Address - City:MATTAPAN
Mailing Address - State:MA
Mailing Address - Zip Code:02126-2834
Mailing Address - Country:US
Mailing Address - Phone:617-533-2300
Mailing Address - Fax:617-282-8201
Practice Address - Street 1:398 NEPONSET AVE
Practice Address - Street 2:
Practice Address - City:DORCHESTER
Practice Address - State:MA
Practice Address - Zip Code:02122-3134
Practice Address - Country:US
Practice Address - Phone:617-282-3200
Practice Address - Fax:617-282-7928
Is Sole Proprietor?:No
Enumeration Date:2006-02-13
Last Update Date:2012-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA37726207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2067196Medicaid
MAM09852Medicare ID - Type Unspecified
MA2067196Medicaid