Provider Demographics
NPI:1245780980
Name:BAUCOM & MINA DERM SURGERY, LLC
Entity Type:Organization
Organization Name:BAUCOM & MINA DERM SURGERY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARY ALICE
Authorized Official - Middle Name:
Authorized Official - Last Name:MINA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:404-844-0496
Mailing Address - Street 1:5555 PEACHTREE DUNWOODY RD
Mailing Address - Street 2:SUITE 206
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-1703
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5555 PEACHTREE DUNWOODY RD
Practice Address - Street 2:SUITE 206
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-1703
Practice Address - Country:US
Practice Address - Phone:404-844-0496
Practice Address - Fax:404-844-0499
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-06
Last Update Date:2023-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Single Specialty