Basic Information
| Provider Information | |||||||||
| NPI: | 1477656304 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BALDWIN | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | D. | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1400 E. KINCAID STREET | ||||||||
| Address2: | ATTN: CREDENTIALING | ||||||||
| City: | MOUNT VERNON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982744127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604282500 | ||||||||
| FaxNumber: | 3604286485 | ||||||||
| Practice Location | |||||||||
| Address1: | 819 SOUTH 13TH STREET | ||||||||
| Address2: | |||||||||
| City: | MOUNT VERNON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98273 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3608146230 | ||||||||
| FaxNumber: | 3608146240 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/06/2006 | ||||||||
| LastUpdateDate: | 01/04/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | 34-00-5880-B | OH | N | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology | 207R00000X | OP60600878 | WA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 207RN0300X | OP60600878 | WA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | 0059120 | 05 | OH | MEDICAID | 0947195 | 05 | OH | MEDICAID |