Healthcare Provider Details

I. General information

NPI: 1912956939
Provider Name (Legal Business Name): DOUGLAS O. BAXLEY CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/08/2006
Last Update Date: 10/17/2025
Certification Date: 10/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

247 S MAIN ST
REIDSVILLE GA
30453-4605
US

IV. Provider business mailing address

285 RHETT CIR
JACKSON AL
36545-8703
US

V. Phone/Fax

Practice location:
  • Phone: 912-557-1000
  • Fax:
Mailing address:
  • Phone: 251-246-9594
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number1-056701
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: