Provider Demographics
NPI:1174707103
Name:BAXLEY MEDICAL CLINIC, LLC
Entity type:Organization
Organization Name:BAXLEY MEDICAL CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:ADRIAN
Authorized Official - Last Name:GRAHAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:912-367-9112
Mailing Address - Street 1:331 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BAXLEY
Mailing Address - State:GA
Mailing Address - Zip Code:31513-0109
Mailing Address - Country:US
Mailing Address - Phone:912-367-9112
Mailing Address - Fax:912-367-6233
Practice Address - Street 1:331 S MAIN ST
Practice Address - Street 2:
Practice Address - City:BAXLEY
Practice Address - State:GA
Practice Address - Zip Code:31513-0109
Practice Address - Country:US
Practice Address - Phone:912-367-9112
Practice Address - Fax:912-367-6233
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-27
Last Update Date:2010-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA057979207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA662027563EMedicaid
GA511G700268Medicare PIN
GAI55876Medicare UPIN