Provider Demographics
NPI:1720100522
Name:GEORGIA DERMATOLOGIC SURGERY CENTER, PC
Entity Type:Organization
Organization Name:GEORGIA DERMATOLOGIC SURGERY CENTER, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:FRANCIS
Authorized Official - Last Name:BAUCOM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:404-943-1996
Mailing Address - Street 1:5555 PEACHTREE DUNWOODY RD NE
Mailing Address - Street 2:SUITE G65
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-1703
Mailing Address - Country:US
Mailing Address - Phone:404-943-1996
Mailing Address - Fax:404-943-9464
Practice Address - Street 1:5555 PEACHTREE DUNWOODY RD NE
Practice Address - Street 2:SUITE G65
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-1703
Practice Address - Country:US
Practice Address - Phone:404-943-1996
Practice Address - Fax:404-943-9464
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-04
Last Update Date:2012-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP3989Medicare ID - Type UnspecifiedGROUP NUMBER FOR MEDICARE