Provider Demographics
NPI:1629176169
Name:BALDWIN, MICHAEL ROY (CRNA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ROY
Last Name:BALDWIN
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 EASTWOOD DR
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:IN
Mailing Address - Zip Code:46563-7950
Mailing Address - Country:US
Mailing Address - Phone:574-361-5857
Mailing Address - Fax:
Practice Address - Street 1:315 EASTWOOD DR
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:IN
Practice Address - Zip Code:46563-7950
Practice Address - Country:US
Practice Address - Phone:574-361-5857
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2013-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209-001985367500000X
IN28077464A367500000X
CO168609 REGISTRY#4405367500000X
MI4704251112367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200373090Medicaid
IN000000519814OtherANTHEM
INP00468258Medicare PIN
IN200373090Medicaid