Provider Demographics
NPI:1326034471
Name:BAERWALDE, KEVIN (PT)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:BAERWALDE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:302 S GREENWOOD ST
Mailing Address - Street 2:
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30240-3122
Mailing Address - Country:US
Mailing Address - Phone:706-884-8360
Mailing Address - Fax:706-884-0265
Practice Address - Street 1:302 S GREENWOOD ST
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30240-3122
Practice Address - Country:US
Practice Address - Phone:706-884-8360
Practice Address - Fax:706-884-0265
Is Sole Proprietor?:No
Enumeration Date:2005-09-23
Last Update Date:2008-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALIC006138225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA611446156001OtherTRICARE-FITNESS FORUM
GA393730OtherBCBS OF GA
GA65BBCKQOtherMEDICARE PIN-FITNESS FORUM
GA112003OtherBCBS-FITNESS FORUM
GA52793122-002OtherBCBS ID NUMBER
GA112003OtherBCBS-FITNESS FORUM
GA611446156001OtherTRICARE-FITNESS FORUM