Healthcare Provider Details

I. General information

NPI: 1629723960
Provider Name (Legal Business Name): SAMUEL BAKER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/15/2022
Last Update Date: 02/15/2022
Certification Date: 02/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

216 KINGSVILLE CT
SAINT LOUIS MO
63119-2433
US

IV. Provider business mailing address

216 KINGSVILLE CT
SAINT LOUIS MO
63119-2433
US

V. Phone/Fax

Practice location:
  • Phone: 314-775-9446
  • Fax:
Mailing address:
  • Phone: 314-775-9446
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: