Basic Information
| Provider Information | |||||||||
| NPI: | 1750655643 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BAXTER | ||||||||
| FirstName: | RYAN | ||||||||
| MiddleName: | JOSEPH | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2906 S 20TH ST | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532153732 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4148975511 | ||||||||
| FaxNumber: | 4146720191 | ||||||||
| Practice Location | |||||||||
| Address1: | 2906 S 20TH ST | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532153732 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4146721353 | ||||||||
| FaxNumber: | 4146724265 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/24/2012 | ||||||||
| LastUpdateDate: | 03/24/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/24/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MD467682 | PA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 4301107467 | MI | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208000000X | 72160-20 | WI | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 4301107467 | MI | N | Allopathic & Osteopathic Physicians | Pediatrics | 207R00000X | 72160-20 | WI | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0230085 | 01 | MI | BCBS | OTHER | 100103241 | 05 | WI | MEDICAID | 114008 | 01 | CA | SID # 114008 | OTHER | 1750655643 | 05 | MI | MEDICAID |