Provider Demographics
NPI:1730104779
Name:BAXLEY, JOHN BAYNARD III (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:BAYNARD
Last Name:BAXLEY
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:JOHN
Other - Middle Name:B
Other - Last Name:BAXLEY
Other - Suffix:III
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2604 PEACH ORCHARD ROAD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30906
Mailing Address - Country:US
Mailing Address - Phone:706-798-4673
Mailing Address - Fax:706-798-7378
Practice Address - Street 1:2604 PEACH ORCHARD ROAD
Practice Address - Street 2:SUITE 200
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30906
Practice Address - Country:US
Practice Address - Phone:706-798-4673
Practice Address - Fax:706-798-7378
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2010-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC8997207Q00000X
GA16872207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC089978Medicaid
SCD39370Medicare UPIN
SC089978Medicaid