Healthcare Provider Details

I. General information

NPI: 1720100522
Provider Name (Legal Business Name): GEORGIA DERMATOLOGIC SURGERY CENTER, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/04/2007
Last Update Date: 01/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5555 PEACHTREE DUNWOODY RD NE SUITE G65
ATLANTA GA
30342-1703
US

IV. Provider business mailing address

5555 PEACHTREE DUNWOODY RD NE SUITE G65
ATLANTA GA
30342-1703
US

V. Phone/Fax

Practice location:
  • Phone: 404-943-1996
  • Fax: 404-943-9464
Mailing address:
  • Phone: 404-943-1996
  • Fax: 404-943-9464

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. MARK FRANCIS BAUCOM
Title or Position: PRESIDENT
Credential: M.D.
Phone: 404-943-1996