Basic Information
Provider Information | |||||||||
NPI: | 1164711313 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BAILEY | ||||||||
FirstName: | TRAVIS | ||||||||
MiddleName: | LEE | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | D.O. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3527 N VALDOSTA RD | ||||||||
Address2: |   | ||||||||
City: | VALDOSTA | ||||||||
State: | GA | ||||||||
PostalCode: | 316026418 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2292472290 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 3527 N VALDOSTA RD | ||||||||
Address2: |   | ||||||||
City: | VALDOSTA | ||||||||
State: | GA | ||||||||
PostalCode: | 316026418 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2292472290 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/28/2011 | ||||||||
LastUpdateDate: | 04/14/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/14/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 5101019452 | MI | N |   | Allopathic & Osteopathic Physicians | Anesthesiology |   | 208VP0000X | 073494 | GA | N |   | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine | 390200000X |   |   | N |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   | 207L00000X | 073494 | GA | Y |   | Allopathic & Osteopathic Physicians | Anesthesiology |   |
No ID Information.