Provider Demographics
NPI:1972774370
Name:DAVID A BAXTER IV, MD, PC
Entity Type:Organization
Organization Name:DAVID A BAXTER IV, MD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SHAREHOLDER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:A
Authorized Official - Last Name:BAXTER
Authorized Official - Suffix:IV
Authorized Official - Credentials:MD
Authorized Official - Phone:307-235-4504
Mailing Address - Street 1:742 S DAVID ST
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82601-3137
Mailing Address - Country:US
Mailing Address - Phone:307-234-9657
Mailing Address - Fax:307-234-0306
Practice Address - Street 1:1233 E 2ND ST
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82601-2926
Practice Address - Country:US
Practice Address - Phone:307-577-7201
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-13
Last Update Date:2014-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY7586A207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY125855900Medicaid
WY125855900Medicaid
WYW21899Medicare PIN