Healthcare Provider Details

I. General information

NPI: 1164620639
Provider Name (Legal Business Name): KEVIN BAKER PHYSCIAL THERAPIST
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/06/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 BAXTER BLVD
PORTLAND ME
04101-1801
US

IV. Provider business mailing address

55 BAXTER BLVD
PORTLAND ME
04101-1801
US

V. Phone/Fax

Practice location:
  • Phone: 207-773-7428
  • Fax: 207-842-6229
Mailing address:
  • Phone: 207-773-7428
  • Fax: 207-842-6229

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number269113
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: