Provider Demographics
NPI:1710987045
Name:BAKER, BENNIE L (MD)
Entity Type:Individual
Prefix:
First Name:BENNIE
Middle Name:L
Last Name:BAKER
Suffix:
Gender:M
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:PO BOX 100567
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29506-2617
Mailing Address - Country:US
Mailing Address - Phone:843-777-2314
Mailing Address - Fax:843-777-5035
Practice Address - Street 1:555 E CHEVES ST
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29506-2617
Practice Address - Country:US
Practice Address - Phone:843-777-2314
Practice Address - Fax:843-777-5035
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2007-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCTL29634207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC296343Medicaid
SCAA1745Medicare UPIN