MEDICARE: BUCKHEAD MOHS SURGICAL CENTER LLC

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	261QA1903X	Ambulatory Surgical Clinic/Center

General Provider Information

NPI Number	:	1497077044
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BUCKHEAD MOHS SURGICAL CENTER LLC

Provider Business Mailing Address
First Line	:	3525 PIEDMONT RD NE
Second Line	:	BUILDING 6, SUITE 220
City	:	ATLANTA
State	:	GA
Zip	:	30305-1578
Country	:	US
Telephone Number	:	404-446-3200
Fax Number	:	404-446-3201

Provider Business Practice Location Address
First Line	:	3525 PIEDMONT RD NE
Second Line	:	BUILDING 6, SUITE 220
City	:	ATLANTA
State	:	GA
Zip	:	30305-1578
Country	:	US
Telephone Number	:	404-446-3200
Fax Number	:	404-446-3201

Authorized Official
Title or Position	:	OWNER/MEDICAL DIRECTOR
Name	:	DR. KATARINA G LEQUEUX-NALOVIC
Credential	:	MD, MPH, FAAD
Telephone Number	:	404-446-3200

Provider Enumeration Date	:	02/24/2010
Last Update Date	:	12/13/2011

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