Provider Demographics
NPI:1659544336
Name:GLEN RAY BAKER JR P S C
Entity Type:Organization
Organization Name:GLEN RAY BAKER JR P S C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GLEN
Authorized Official - Middle Name:RAY
Authorized Official - Last Name:BAKER
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:606-523-1553
Mailing Address - Street 1:1200 RAVENWOOD DR
Mailing Address - Street 2:
Mailing Address - City:CORBIN
Mailing Address - State:KY
Mailing Address - Zip Code:40701-2172
Mailing Address - Country:US
Mailing Address - Phone:606-523-1553
Mailing Address - Fax:606-523-1593
Practice Address - Street 1:1007 CUMBERLAND FALLS HWY
Practice Address - Street 2:
Practice Address - City:CORBIN
Practice Address - State:KY
Practice Address - Zip Code:40701-2714
Practice Address - Country:US
Practice Address - Phone:606-523-1553
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-02
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY15090207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty