Provider Demographics
NPI:1952377566
Name:BAKER, BRUCE HENRY (MD)
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:HENRY
Last Name:BAKER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3210 EAGLE RUN DR NE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525
Mailing Address - Country:US
Mailing Address - Phone:616-957-1200
Mailing Address - Fax:616-957-1297
Practice Address - Street 1:3210 EAGLE RUN DR
Practice Address - Street 2:SUITE 200
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525
Practice Address - Country:US
Practice Address - Phone:616-957-1200
Practice Address - Fax:616-957-1297
Is Sole Proprietor?:No
Enumeration Date:2006-02-23
Last Update Date:2009-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI100005207QA0401X, 207RA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
No207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4786146Medicaid
MI4786146Medicaid
B46178Medicare UPIN