Healthcare Provider Details

I. General information

NPI: 1104867480
Provider Name (Legal Business Name): RANDAL BAKER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2006
Last Update Date: 06/28/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2060 E PARIS AVE SE SUITE 100
GRAND RAPIDS MI
49546-6113
US

IV. Provider business mailing address

2060 E PARIS AVE SE SUITE 100
GRAND RAPIDS MI
49546-6113
US

V. Phone/Fax

Practice location:
  • Phone: 616-956-6100
  • Fax: 616-956-6637
Mailing address:
  • Phone: 616-956-6657
  • Fax: 616-956-6637

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number4301057752
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: