Basic Information
Provider Information
NPI: 1003801796
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: BAKER
FirstName: JOHN
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential: MD
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: PO BOX 400
Address2:  
City: JACKSON
State: TN
PostalCode: 383020400
CountryCode: US
TelephoneNumber: 7314238697
FaxNumber: 7314225743
Practice Location
Address1: 700 W FOREST AVE
Address2: STE 300
City: JACKSON
State: TN
PostalCode: 383013937
CountryCode: US
TelephoneNumber: 7314220347
FaxNumber: 7314220409
Other Information
ProviderEnumerationDate: 09/19/2005
LastUpdateDate: 11/29/2012
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207RC0000X28097TNY Allopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease

ID Information
IDTypeStateIssuerDescription
150576005TN MEDICAID
380782405TN MEDICAID


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