Provider Demographics
NPI:1649305186
Name:TERRY BAKER, M.D.P.A.
Entity type:Organization
Organization Name:TERRY BAKER, M.D.P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:BAKER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-552-9530
Mailing Address - Street 1:3200 CHANNING WAY
Mailing Address - Street 2:STE. A-105
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-7546
Mailing Address - Country:US
Mailing Address - Phone:208-552-9530
Mailing Address - Fax:208-522-6262
Practice Address - Street 1:3200 CHANNING WAY
Practice Address - Street 2:STE. A-105
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7546
Practice Address - Country:US
Practice Address - Phone:208-552-9530
Practice Address - Fax:208-522-6262
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TERRY BAKER, MDPA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-02-23
Last Update Date:2007-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-8221207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1100633Medicare PIN
IDH14207Medicare UPIN