MEDICARE: MR. MARK ALLAN KNAUTZ MEDICAL DOCTOR

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	207N00000X	Dermatology Physician	041328	GA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	070008625	OTHER	GA	MEDICARE RAILROAD

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	52635067	OTHER	GA	BCBS

General Provider Information

NPI Number	:	1790743300
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MARK ALLAN KNAUTZ MEDICAL DOCTOR

Provider Business Mailing Address
First Line	:	111 MARBLE MILL RD NW
Second Line	:
City	:	MARIETTA
State	:	GA
Zip	:	30060-1047
Country	:	US
Telephone Number	:	770-422-1013
Fax Number	:	770-514-5996

Provider Business Practice Location Address
First Line	:	5041 DALLAS HWY
Second Line	:	SUITE D
City	:	POWDER SPRINGS
State	:	GA
Zip	:	30127-6458
Country	:	US
Telephone Number	:	770-427-5467
Fax Number	:	770-427-6340

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

Provider Enumeration Date	:	05/03/2006
Last Update Date	:	12/07/2011

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