Basic Information
| Provider Information | |||||||||
| NPI: | 1285720425 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BAKER | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | WAYNE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 776351 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606776351 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025889490 | ||||||||
| FaxNumber: | 5022725116 | ||||||||
| Practice Location | |||||||||
| Address1: | 3430 NEWBURG RD STE 150 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402182497 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5024599127 | ||||||||
| FaxNumber: | 5024592156 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2006 | ||||||||
| LastUpdateDate: | 10/11/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 20129 | KY | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RP1001X | 20129 | KY | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | 207RS0012X | 20129 | KY | N | Allopathic & Osteopathic Physicians | Internal Medicine | Sleep Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200003290 | 01 | KY | INDIANA MEDICAID | OTHER | 64201296 | 05 | KY | MEDICAID |