Healthcare Provider Details

I. General information

NPI: 1649224668
Provider Name (Legal Business Name): RENEATHIA PRIMUS BAKER MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: RENEATHIA LASHANNE PRIMUS MD

II. Dates (important events)

Enumeration Date: 05/22/2006
Last Update Date: 02/21/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 MOUNT ZION PKWY SOUTHWOOD MEDICAL OFFICE DEPARTMENT OF PEDIATRICS
JONESBORO GA
30236
US

IV. Provider business mailing address

3495 PIEDMONT ROAD NE NINE PIEDMONT CENTER
ATLANTA GA
30305
US

V. Phone/Fax

Practice location:
  • Phone: 770-603-3614
  • Fax:
Mailing address:
  • Phone: 404-949-5019
  • Fax: 404-364-4985

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number049250
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: