Healthcare Provider Details

I. General information

NPI: 1912128448
Provider Name (Legal Business Name): CHAMP L. BAKER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2007
Last Update Date: 11/20/2020
Certification Date: 11/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6262 VETERANS PKWY
COLUMBUS GA
31909-3540
US

IV. Provider business mailing address

PO BOX 370
FORTSON GA
31808-0370
US

V. Phone/Fax

Practice location:
  • Phone: 706-324-6661
  • Fax: 706-494-3201
Mailing address:
  • Phone:
  • Fax: 706-494-3008

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number061038
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberMD.28831
License Number StateAL
# 3
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License NumberMD.28831
License Number StateAL
# 4
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number61038
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: