MEDICARE: NICHOLAS M BATH M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208800000X	Urology Physician	016555	GA

General Provider Information

NPI Number	:	1477661650
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICHOLAS M BATH M.D.

Provider Business Mailing Address
First Line	:	175 COUNTRY CLUB DR
Second Line	:	BLDG 300, SUITE D
City	:	STOCKBRIDGE
State	:	GA
Zip	:	30281-9054
Country	:	US
Telephone Number	:	678-284-4040
Fax Number	:	678-284-4076

Provider Business Practice Location Address
First Line	:	4142 MILL ST NE
Second Line	:
City	:	COVINGTON
State	:	GA
Zip	:	30014-2540
Country	:	US
Telephone Number	:	770-787-7311
Fax Number	:	770-787-9349

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/28/2006
Last Update Date	:	03/07/2023

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