Healthcare Provider Details

I. General information

NPI: 1699790071
Provider Name (Legal Business Name): MICHAEL A. BAKARICH D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2006
Last Update Date: 08/18/2022
Certification Date: 08/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1602 VERNON RD STE 200
LAGRANGE GA
30240-4129
US

IV. Provider business mailing address

1602 VERNON RD STE 200
LAGRANGE GA
30240-4129
US

V. Phone/Fax

Practice location:
  • Phone: 706-880-7252
  • Fax: 770-999-2687
Mailing address:
  • Phone: 706-880-7252
  • Fax: 770-999-2687

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number02655
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number060793
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number060793
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: