Healthcare Provider Details

I. General information

NPI: 1629427422
Provider Name (Legal Business Name): CHRISTIAN BAKER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2016
Last Update Date: 07/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1079 DUTCH FORK RD
IRMO SC
29063-8725
US

IV. Provider business mailing address

PO BOX 743904
ATLANTA GA
30374-3904
US

V. Phone/Fax

Practice location:
  • Phone: 803-749-8900
  • Fax: 803-749-8899
Mailing address:
  • Phone: 803-296-7320
  • Fax: 803-296-7330

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number39644
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: