=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154870509
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KENNETH L BALDWIN M D INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/27/2016
-----------------------------------------------------
Last Update Date | 09/27/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1304 ELLA ST SUITE B-1
-----------------------------------------------------
City | SAN LUIS OBISPO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93401-4100
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-546-8662
-----------------------------------------------------
Fax | 805-546-8665
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1304 ELLA ST SUITE B
-----------------------------------------------------
City | SAN LUIS OBISPO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93401-4100
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-546-8662
-----------------------------------------------------
Fax | 805-546-8665
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATION
-----------------------------------------------------
Name | MRS. TINA MARIE GARCIA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 805-546-8662
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207X00000X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery Physician
-----------------------------------------------------
License Number | G34268
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------