Basic Information
| Provider Information | |||||||||
| NPI: | 1073756631 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BAUSER-HEATON | ||||||||
| FirstName: | HOLLY | ||||||||
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| Credential: | M.D., PH.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2835 BRANDYWINE RD STE 300 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303415540 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4042562593 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1405 CLIFTON RD NE | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303221060 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4042562593 | ||||||||
| FaxNumber: | 7704889408 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/13/2009 | ||||||||
| LastUpdateDate: | 02/25/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 094041 | GA | N | Allopathic & Osteopathic Physicians | Pediatrics | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 2080P0202X | 076296 | GA | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Cardiology |
ID Information
| ID | Type | State | Issuer | Description | 003177562B | 05 | GA | MEDICAID |