Healthcare Provider Details

I. General information

NPI: 1760109912
Provider Name (Legal Business Name): RYAN BAXTER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/27/2022
Last Update Date: 10/27/2022
Certification Date: 10/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11301 BROOKLYN RD
BROOKLYN MI
49230-8485
US

IV. Provider business mailing address

6451 SKYLARK DR
JACKSON MI
49201-8549
US

V. Phone/Fax

Practice location:
  • Phone: 517-592-2475
  • Fax:
Mailing address:
  • Phone: 517-395-9584
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: