Healthcare Provider Details

I. General information

NPI: 1598627911
Provider Name (Legal Business Name): MATTHEW BAKER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/25/2025
Last Update Date: 11/25/2025
Certification Date: 11/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1338 N LASALLE ST
INDIANAPOLIS IN
46201-1416
US

IV. Provider business mailing address

1338 N LASALLE ST
INDIANAPOLIS IN
46201-1416
US

V. Phone/Fax

Practice location:
  • Phone: 317-987-8212
  • Fax:
Mailing address:
  • Phone: 317-987-8212
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WA0400X
TaxonomyAddiction (Substance Use Disorder) Registered Nurse
License Number28244116A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: