Provider Demographics
NPI:1730372624
Name:JACK R. BAKER, D.O., INC.
Entity type:Organization
Organization Name:JACK R. BAKER, D.O., INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:ROSS
Authorized Official - Last Name:BAKER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:330-493-5555
Mailing Address - Street 1:4590 DRESSLER RD NW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44718-2546
Mailing Address - Country:US
Mailing Address - Phone:330-492-5555
Mailing Address - Fax:330-492-7808
Practice Address - Street 1:4590 DRESSLER RD NW
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44718-2546
Practice Address - Country:US
Practice Address - Phone:330-492-5555
Practice Address - Fax:330-492-7808
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-23
Last Update Date:2007-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34-00-3232B208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0672884Medicaid
OHBA0509465Medicare PIN
OH0672884Medicaid