Provider Demographics
NPI:1841269818
Name:ROBERT H. BAKER
Entity type:Organization
Organization Name:ROBERT H. BAKER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DISPENSER
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:H
Authorized Official - Last Name:FARGASON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-299-1141
Mailing Address - Street 1:917 N INDIAN CREEK DR
Mailing Address - Street 2:P.O. BOX 91
Mailing Address - City:CLARKSTON
Mailing Address - State:GA
Mailing Address - Zip Code:30021-2245
Mailing Address - Country:US
Mailing Address - Phone:404-299-1141
Mailing Address - Fax:404-299-8195
Practice Address - Street 1:917 N INDIAN CREEK DR
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:GA
Practice Address - Zip Code:30021-2245
Practice Address - Country:US
Practice Address - Phone:404-299-1141
Practice Address - Fax:404-299-8195
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-14
Last Update Date:2008-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAHADE000064237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument SpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000041104AMedicaid