Healthcare Provider Details

I. General information

NPI: 1093704645
Provider Name (Legal Business Name): JANICE K. BAIN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2005
Last Update Date: 01/13/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4885 COLLINS LAKE DR
MABLETON GA
30126-1794
US

IV. Provider business mailing address

4885 COLLINS LAKE DR
MABLETON GA
30126-1794
US

V. Phone/Fax

Practice location:
  • Phone: 470-725-2496
  • Fax:
Mailing address:
  • Phone: 470-725-2496
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD60452100
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number056967
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: