MEDICARE: DR. MICHELLE L. BAACK MD

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	208000000X	Pediatrics Physician	4522	SD

General Provider Information

NPI Number	:	1316911266
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MICHELLE L. BAACK MD

Provider Business Mailing Address
First Line	:	1600 W. 22ND ST
Second Line	:	SANFORD CHILDREN'S SPECIALTY CLINIC
City	:	SIOUX FALLS
State	:	SD
Zip	:	57105-1521
Country	:	US
Telephone Number	:	605-312-1000
Fax Number	:	605-312-1001

Provider Business Practice Location Address
First Line	:	1600 W 22ND ST
Second Line	:
City	:	SIOUX FALLS
State	:	SD
Zip	:	57105-1521
Country	:	US
Telephone Number	:	605-312-1000
Fax Number	:	605-312-1001

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

Provider Enumeration Date	:	02/16/2006
Last Update Date	:	07/21/2011

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