Healthcare Provider Details

I. General information

NPI: 1972182988
Provider Name (Legal Business Name): CHARLES J BAKER IV
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/06/2021
Last Update Date: 10/21/2025
Certification Date: 10/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1364 CLIFTON RD NE
ATLANTA GA
30322-1059
US

IV. Provider business mailing address

1364 CLIFTON RD NE
ATLANTA GA
30322-1059
US

V. Phone/Fax

Practice location:
  • Phone: 404-778-3903
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number94425
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: