Provider Demographics
NPI:1316028467
Name:BALDWIN, MAX RUSSELL JR (PAC)
Entity Type:Individual
Prefix:MR
First Name:MAX
Middle Name:RUSSELL
Last Name:BALDWIN
Suffix:JR
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:611 E. VILLANOW ST.
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:GA
Mailing Address - Zip Code:30728
Mailing Address - Country:US
Mailing Address - Phone:706-638-1606
Mailing Address - Fax:706-638-9987
Practice Address - Street 1:611 E. VILLANOW ST.
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:GA
Practice Address - Zip Code:30728
Practice Address - Country:US
Practice Address - Phone:706-638-1606
Practice Address - Fax:706-638-9987
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2013-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003194207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine