Provider Demographics
NPI:1912128448
Name:BAKER, CHAMP L (MD)
Entity Type:Individual
Prefix:
First Name:CHAMP
Middle Name:L
Last Name:BAKER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 370
Mailing Address - Street 2:
Mailing Address - City:FORTSON
Mailing Address - State:GA
Mailing Address - Zip Code:31808-0370
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:706-494-3008
Practice Address - Street 1:6262 VETERANS PKWY
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31909-3540
Practice Address - Country:US
Practice Address - Phone:706-324-6661
Practice Address - Fax:706-494-3201
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2020-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA061038207X00000X
ALMD.28831207X00000X, 207XX0005X
GA61038207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK39049Medicare PIN
ILK39048Medicare PIN
GA511I200057Medicare PIN
AL510I200040Medicare PIN