Healthcare Provider Details

I. General information

NPI: 1861235822
Provider Name (Legal Business Name): JEFFREY ROBERT BAKER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2024
Last Update Date: 06/17/2024
Certification Date: 06/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 N 1ST ST
SPRINGFIELD IL
62702-3757
US

IV. Provider business mailing address

PO BOX 19638
SPRINGFIELD IL
62794-9638
US

V. Phone/Fax

Practice location:
  • Phone: 217-545-6155
  • Fax:
Mailing address:
  • Phone: 217-545-6155
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number125084064
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: