Provider Demographics
NPI:1336185339
Name:BAK, EWA B (MD)
Entity Type:Individual
Prefix:
First Name:EWA
Middle Name:B
Last Name:BAK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1611 S GREEN RD STE 260
Mailing Address - Street 2:
Mailing Address - City:SOUTH EUCLID
Mailing Address - State:OH
Mailing Address - Zip Code:44121-4192
Mailing Address - Country:US
Mailing Address - Phone:216-297-2059
Mailing Address - Fax:216-297-2066
Practice Address - Street 1:1611 S GREEN RD STE 260
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44121-4192
Practice Address - Country:US
Practice Address - Phone:216-297-2059
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2020-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY36870207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000216081OtherBLUE CROSS & BLUE SHIELD
KY022092900OtherBLACK LUNG INSURANCE
KY7140400OtherAETNA INSURANCE COMPANY
KY1283881OtherUNITED MINE WORKERS ASSOC
KY64046006Medicaid
KY110231108OtherRAILROAD MEDICARE
0214527Medicare PIN
KY110231108OtherRAILROAD MEDICARE