=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487681342
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BLAISE W BAXTER MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/27/2006
-----------------------------------------------------
Last Update Date | 07/07/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1100 VAN NESS AVE
-----------------------------------------------------
City | SAN FRANCISCO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94109-6978
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-600-7887
-----------------------------------------------------
Fax | 415-369-1395
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 325 DISTEL CIR
-----------------------------------------------------
City | LOS ALTOS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94022-1408
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-600-7887
-----------------------------------------------------
Fax | 415-369-1395
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number | 31416
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number | C171504
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 2085R0204X
-----------------------------------------------------
Taxonomy Name | Vascular & Interventional Radiology Physician
-----------------------------------------------------
License Number | MD19382
-----------------------------------------------------
License Number State | RI
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 2085R0204X
-----------------------------------------------------
Taxonomy Name | Vascular & Interventional Radiology Physician
-----------------------------------------------------
License Number | MD468416
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------