Basic Information
| Provider Information | |||||||||
| NPI: | 1649224668 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BAKER | ||||||||
| FirstName: | RENEATHIA | ||||||||
| MiddleName: | PRIMUS | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PRIMUS | ||||||||
| OtherFirstName: | RENEATHIA | ||||||||
| OtherMiddleName: | LASHANNE | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3495 PIEDMONT ROAD NE | ||||||||
| Address2: | NINE PIEDMONT CENTER | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4049495019 | ||||||||
| FaxNumber: | 4043644985 | ||||||||
| Practice Location | |||||||||
| Address1: | 2400 MOUNT ZION PKWY | ||||||||
| Address2: | SOUTHWOOD MEDICAL OFFICE DEPARTMENT OF PEDIATRICS | ||||||||
| City: | JONESBORO | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30236 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7706033614 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2006 | ||||||||
| LastUpdateDate: | 02/21/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 049250 | GA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.