MEDICARE: EWA B BAK 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	207R00000X	Internal Medicine Physician	36870	KY

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
6	110231108	OTHER	KY	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000000216081	OTHER	KY	BLUE CROSS & BLUE SHIELD
2	022092900	OTHER	KY	BLACK LUNG INSURANCE
3	7140400	OTHER	KY	AETNA INSURANCE COMPANY
4	1283881	OTHER	KY	UNITED MINE WORKERS ASSOC
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1336185339
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EWA B BAK M.D.

Provider Business Mailing Address
First Line	:	1611 S GREEN RD STE 260
Second Line	:
City	:	SOUTH EUCLID
State	:	OH
Zip	:	44121-4192
Country	:	US
Telephone Number	:	216-297-2059
Fax Number	:	216-297-2066

Provider Business Practice Location Address
First Line	:	1611 S GREEN RD STE 260
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44121-4192
Country	:	US
Telephone Number	:	216-297-2059
Fax Number	:

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

Provider Enumeration Date	:	06/20/2006
Last Update Date	:	12/16/2020

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Directions to “ EWA B BAK M.D.” Practice Location

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