Basic Information
| Provider Information | |||||||||
| NPI: | 1972774370 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DAVID A BAXTER IV, MD, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 742 S DAVID ST | ||||||||
| Address2: | |||||||||
| City: | CASPER | ||||||||
| State: | WY | ||||||||
| PostalCode: | 826013137 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3072349657 | ||||||||
| FaxNumber: | 3072340306 | ||||||||
| Practice Location | |||||||||
| Address1: | 1233 E 2ND ST | ||||||||
| Address2: | |||||||||
| City: | CASPER | ||||||||
| State: | WY | ||||||||
| PostalCode: | 826012926 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3075777201 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/13/2008 | ||||||||
| LastUpdateDate: | 01/16/2014 | ||||||||
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| AuthorizedOfficialLastName: | BAXTER | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | SHAREHOLDER | ||||||||
| AuthorizedOfficialTelephone: | 3072354504 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | IV | ||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 7586A | WY | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 125855900 | 05 | WY | MEDICAID |