Healthcare Provider Details

I. General information

NPI: 1780676940
Provider Name (Legal Business Name): GARY S BAXTER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2005
Last Update Date: 11/19/2020
Certification Date: 11/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2227 US HIGHWAY 41 N
TIFTON GA
31794
US

IV. Provider business mailing address

907 18TH ST E SUITE 150
TIFTON GA
31794-3643
US

V. Phone/Fax

Practice location:
  • Phone: 229-386-4200
  • Fax: 229-386-5571
Mailing address:
  • Phone: 229-353-3422
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number26452
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: