Provider Demographics
NPI:1568633543
Name:MICHAEL L BAKER DO PA
Entity Type:Organization
Organization Name:MICHAEL L BAKER DO PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT AND CEO
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:LEO
Authorized Official - Last Name:BAKER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:662-746-8777
Mailing Address - Street 1:129 S. MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:YAZOO CITY
Mailing Address - State:MS
Mailing Address - Zip Code:39194
Mailing Address - Country:US
Mailing Address - Phone:662-746-8777
Mailing Address - Fax:662-746-8778
Practice Address - Street 1:129 S MAIN ST
Practice Address - Street 2:
Practice Address - City:YAZOO CITY
Practice Address - State:MS
Practice Address - Zip Code:39194-4007
Practice Address - Country:US
Practice Address - Phone:662-746-8777
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-18
Last Update Date:2008-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS15475207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09016054Medicaid
MS09016054Medicaid
MSH38191Medicare UPIN