Healthcare Provider Details

I. General information

NPI: 1649496464
Provider Name (Legal Business Name): ELLEN LEE BAXTER D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2007
Last Update Date: 11/03/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6005 MONCLOVA RD SUITE 320
MAUMEE OH
43537-1864
US

IV. Provider business mailing address

6005 MONCLOVA RD SUITE 320
MAUMEE OH
43537-1864
US

V. Phone/Fax

Practice location:
  • Phone: 419-578-7555
  • Fax: 419-539-6336
Mailing address:
  • Phone: 419-578-7555
  • Fax: 419-539-6336

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207YS0123X
TaxonomyFacial Plastic Surgery Physician
License Number5101016209
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207YS0123X
TaxonomyFacial Plastic Surgery Physician
License Number34009606
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: