Provider Demographics
NPI:1801959101
Name:SOUTH FULTON DERMATOLOGY ASSOCIATES,LLP
Entity type:Organization
Organization Name:SOUTH FULTON DERMATOLOGY ASSOCIATES,LLP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:F
Authorized Official - Last Name:BAUCOM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:404-763-4153
Mailing Address - Street 1:1006 STOVALL BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30319
Mailing Address - Country:US
Mailing Address - Phone:404-869-4428
Mailing Address - Fax:
Practice Address - Street 1:2719 FELTON DR
Practice Address - Street 2:
Practice Address - City:EAST POINT
Practice Address - State:GA
Practice Address - Zip Code:30344-3603
Practice Address - Country:US
Practice Address - Phone:404-763-4153
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAG05375Medicare UPIN
GAGRP350Medicare ID - Type UnspecifiedGROUP #