Provider Demographics
NPI:1487120325
Name:EDMOND L BAKER JR MD PC
Entity type:Organization
Organization Name:EDMOND L BAKER JR MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EDMOND
Authorized Official - Middle Name:LOWE
Authorized Official - Last Name:BAKER
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:480-280-7588
Mailing Address - Street 1:743 E WINDSONG DR
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85048-2069
Mailing Address - Country:US
Mailing Address - Phone:602-935-6270
Mailing Address - Fax:602-899-1231
Practice Address - Street 1:926 E MCDOWELL RD STE 134
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85006-2521
Practice Address - Country:US
Practice Address - Phone:602-935-6270
Practice Address - Fax:602-899-1231
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-18
Last Update Date:2018-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QF0050XAmbulatory Health Care FacilitiesClinic/CenterFamily Planning, Non-Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ467843Medicaid