Provider Demographics
NPI:1811220577
Name:SHORT, BARON K
Entity type:Individual
Prefix:MR
First Name:BARON
Middle Name:K
Last Name:SHORT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:729 W US HIGHWAY 50
Mailing Address - Street 2:STE F
Mailing Address - City:O FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-1972
Mailing Address - Country:US
Mailing Address - Phone:618-447-3392
Mailing Address - Fax:
Practice Address - Street 1:729 W US HIGHWAY 50
Practice Address - Street 2:STE F
Practice Address - City:O FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-1972
Practice Address - Country:US
Practice Address - Phone:618-447-3392
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-14
Last Update Date:2009-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL3949-4810332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment