Provider Demographics
NPI:1760477608
Name:BACKER, CARL LEWIS (MD)
Entity Type:Individual
Prefix:
First Name:CARL
Middle Name:LEWIS
Last Name:BACKER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3333 BURNET AVE
Mailing Address - Street 2:MLC 2004
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45229-3026
Mailing Address - Country:US
Mailing Address - Phone:513-636-4770
Mailing Address - Fax:513-636-3847
Practice Address - Street 1:UK HEALTHCARE 740 S LIMESTONE SUITE A301
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40536-2991
Practice Address - Country:US
Practice Address - Phone:859-323-6494
Practice Address - Fax:859-257-4682
Is Sole Proprietor?:No
Enumeration Date:2005-09-16
Last Update Date:2020-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.139651208G00000X
KYTP117208G00000X
KY53982208G00000X
IL036064156208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036064156Medicaid
MS05825879Medicaid
IL1627123OtherBCBS PROVIDER ID
IL363283051OtherOWCP PROVIDER ID
KY6435508Medicaid
IL1627123OtherBCBS PROVIDER ID
ILL05701Medicare PIN