MEDICARE: FAIRCLOTH BAKEMAN PARTNERSHIP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223S0112X	Oral and Maxillofacial Surgery (Dentist)

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	7561	OTHER	SC	MEDICARE GROUP PIN
3	GRP5093	OTHER	GA	MEDICARE GROUP PIN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1649209859
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FAIRCLOTH BAKEMAN PARTNERSHIP

Provider Business Mailing Address
First Line	:	1222 GEORGE C WILSON DR
Second Line	:
City	:	AUGUSTA
State	:	GA
Zip	:	30909-4502
Country	:	US
Telephone Number	:	706-868-9500
Fax Number	:	706-868-5081

Provider Business Practice Location Address
First Line	:	1222 GEORGE C WILSON DR
Second Line	:
City	:	AUGUSTA
State	:	GA
Zip	:	30909-4502
Country	:	US
Telephone Number	:	706-868-9500
Fax Number	:	706-868-5081

Authorized Official
Title or Position	:	INSURANCE COORDINATOR
Name	:	MRS. PAMELA S COCKRELL
Credential	:
Telephone Number	:	706-868-9500

Provider Enumeration Date	:	07/01/2006
Last Update Date	:	09/24/2008

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Practice Location Address:

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Practice Location Address:

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1871650309 — GEORGIA INTERNAL MEDICINE PARTNERS, LLC
Practice Location Address:

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Directions to “FAIRCLOTH BAKEMAN PARTNERSHIP ” Practice Location

Language	Start Address	Practice Location

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