Provider Demographics
NPI:1215610498
Name:BAKER, MATTHEW ROBERT ELLSWORTH (MD)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:ROBERT ELLSWORTH
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 1:2160 S 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:MAYWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60153-3328
Mailing Address - Country:US
Mailing Address - Phone:708-216-7766
Mailing Address - Fax:
Practice Address - Street 1:1775 BALLARD RD
Practice Address - Street 2:
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068-1005
Practice Address - Country:US
Practice Address - Phone:473-189-3408
Practice Address - Fax:847-318-2966
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-14
Last Update Date:2024-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1215610498207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine