Provider Demographics
NPI:1356429765
Name:ASC OF GEORGIA DERMATOLOGIC SURGERY
Entity type:Organization
Organization Name:ASC OF GEORGIA DERMATOLOGIC SURGERY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:BAUCOM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:404-844-0496
Mailing Address - Street 1:5555 PEACHTREE DUNWOODY RD STE 220
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-1724
Mailing Address - Country:US
Mailing Address - Phone:404-844-0496
Mailing Address - Fax:404-844-0499
Practice Address - Street 1:5555 PEACHTREE DUNWOODY RD STE 220
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-1724
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:2006-11-02
Last Update Date:2023-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA111265ASCAMedicare ID - Type UnspecifiedMEDICARE PROVIDER ID