MEDICARE: DR. KENNETH C BAKER 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	F3730	TX

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
2	101821	OTHER	TX	SUPERIOR CHIPS
3	4535342	OTHER	TX	AETNA
4	10008791	OTHER	TX	AMERIGROUP

General Provider Information

NPI Number	:	1619970720
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KENNETH C BAKER MD

Provider Business Mailing Address
First Line	:	PO BOX 844658
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75284-4658
Country	:	US
Telephone Number	:	800-994-0371
Fax Number	:	254-215-9722

Provider Business Practice Location Address
First Line	:	600 N PARK ST
Second Line	:
City	:	BRENHAM
State	:	TX
Zip	:	77833
Country	:	US
Telephone Number	:	979-836-6153
Fax Number	:

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

Provider Enumeration Date	:	05/23/2005
Last Update Date	:	09/19/2018

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