Healthcare Provider Details

I. General information

NPI: 1194138602
Provider Name (Legal Business Name): MAIMOUNA BAH M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/03/2014
Last Update Date: 05/28/2026
Certification Date: 05/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45 DRISKELL AVE SW
MABLETON GA
30126-1824
US

IV. Provider business mailing address

45 DRISKELL AVE SW
MABLETON GA
30126-1824
US

V. Phone/Fax

Practice location:
  • Phone: 609-321-1190
  • Fax:
Mailing address:
  • Phone: 609-321-1190
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number83198
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberMT207010
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number83198
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: