MEDICARE: DR. DOMINIQUE C BAILEY MD, FAAP

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	208000000X	Pediatrics Physician	MD76939	GA
2	208000000X	Pediatrics Physician	MD040747L	PA

General Provider Information

NPI Number	:	1801883384
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DOMINIQUE C BAILEY MD, FAAP

Provider Business Mailing Address
First Line	:	165 BLUE RIDGE OVERLOOK
Second Line	:
City	:	BLUE RIDGE
State	:	GA
Zip	:	30513-4431
Country	:	US
Telephone Number	:	706-946-5608
Fax Number	:	706-374-7628

Provider Business Practice Location Address
First Line	:	2401 NORTHAMPTON ST STE 210
Second Line	:
City	:	EASTON
State	:	PA
Zip	:	18045-2764
Country	:	US
Telephone Number	:	484-591-7470
Fax Number	:

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

Provider Enumeration Date	:	09/30/2005
Last Update Date	:	07/31/2023

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