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NPI Code Detail

MEDICARE: SOUTH FULTON DERMATOLOGY ASSOCIATES,LLP

MEDICARE: SOUTH FULTON DERMATOLOGY ASSOCIATES,LLP
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
1207NS0135XProcedural Dermatology PhysicianGA

General Provider Information

NPI Number : 1801959101
Entity Type Code : Organization
Provider Name (Legal Business Name) : SOUTH FULTON DERMATOLOGY ASSOCIATES,LLP
Provider Business Mailing Address
First Line : 1006 STOVALL BOULEVARD
Second Line :
City : ATLANTA
State : GA
Zip : 30319
Country : US
Telephone Number : 404-869-4428
Fax Number :
Provider Business Practice Location Address
First Line : 2719 FELTON DR
Second Line :
City : EAST POINT
State : GA
Zip : 30344-3603
Country : US
Telephone Number : 404-763-4153
Fax Number :
Authorized Official
Title or Position : PARTNER
Name : MARK F BAUCOM
Credential : M.D.
Telephone Number : 404-763-4153
Provider Enumeration Date : 12/18/2006
Last Update Date : 08/22/2020

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