Provider Demographics
NPI:1699752493
Name:BAKER, JACK R (MD)
Entity type:Individual
Prefix:DR
First Name:JACK
Middle Name:R
Last Name:BAKER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:210 25TH AVE N STE 1204
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37203-1620
Mailing Address - Country:US
Mailing Address - Phone:615-312-0600
Mailing Address - Fax:615-320-3259
Practice Address - Street 1:210 25TH AVE N STE 1204
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37203-1620
Practice Address - Country:US
Practice Address - Phone:615-312-0600
Practice Address - Fax:615-320-3259
Is Sole Proprietor?:No
Enumeration Date:2005-12-22
Last Update Date:2021-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN186152085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64037765Medicaid
TN1509034Medicaid
TN3051603Medicaid
TN3051608Medicaid
TN3718587Medicaid
TN3721492OtherRA GROUP
300116569OtherRR MEDICARE
TN3159114OtherBLUE CROSS BLUE SHIELD TN
TN3721492Medicaid
E38807Medicare UPIN
300116569OtherRR MEDICARE
3791307Medicare ID - Type Unspecified
TN3791307Medicare ID - Type UnspecifiedSMRI GROUP
TN3718587Medicaid