MEDICARE: DR. BRAD ROBIN BAACK M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207ND0101X	MOHS-Micrographic Surgery Physician	DR.0039315	CO
2	207ND0900X	Dermatopathology Physician	39315	CO
3	207NS0135X	Procedural Dermatology Physician	39315	CO
4	207N00000X	Dermatology Physician	DR.0039315	CO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1104856061
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BRAD ROBIN BAACK M.D.

Provider Business Mailing Address
First Line	:	4795 LARIMER PKWY
Second Line	:
City	:	JOHNSTOWN
State	:	CO
Zip	:	80534-9021
Country	:	US
Telephone Number	:	970-342-2222
Fax Number	:	970-342-2233

Provider Business Practice Location Address
First Line	:	4795 LARIMER PKWY STE 150
Second Line	:
City	:	JOHNSTOWN
State	:	CO
Zip	:	80534-9021
Country	:	US
Telephone Number	:	970-342-2222
Fax Number	:	970-342-2233

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/04/2006
Last Update Date	:	07/18/2024

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