Provider Demographics
NPI:1205897428
Name:BAKER, KIM WILLIS (MD)
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:WILLIS
Last Name:BAKER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:K
Other - Middle Name:MICHAEL
Other - Last Name:BAKER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:134 SOUTHVIEW ST
Mailing Address - Street 2:
Mailing Address - City:OWATONNA
Mailing Address - State:MN
Mailing Address - Zip Code:55060-3241
Mailing Address - Country:US
Mailing Address - Phone:507-451-1120
Mailing Address - Fax:507-444-6287
Practice Address - Street 1:134 SOUTHVIEW ST
Practice Address - Street 2:
Practice Address - City:OWATONNA
Practice Address - State:MN
Practice Address - Zip Code:55060-3241
Practice Address - Country:US
Practice Address - Phone:507-451-1120
Practice Address - Fax:507-444-6287
Is Sole Proprietor?:No
Enumeration Date:2006-03-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN28668207P00000X
IL36-072860207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
C44968Medicare UPIN