MEDICARE: DR. ASHTON GRACE DOUGLAS PT, DPT, ATC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	12903	TN

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
5	12903	OTHER	TN	MEDICARE REPLACEMENT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	12903	OTHER	TN	MEDRISK
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	12903	OTHER	TN	TRI-CARE
4	12903	OTHER	TN	COMMERCIAL
6	12903	OTHER	TN	TRIWEST
7	12903	OTHER	TN	WORKER'S COMPENSATION

General Provider Information

NPI Number	:	1174149520
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ASHTON GRACE DOUGLAS PT, DPT, ATC

Provider Business Mailing Address
First Line	:	1100 CIRCLE 75 PKWY SE STE 1400
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30339-3067
Country	:	US
Telephone Number	:	678-981-3543
Fax Number	:	404-777-1311

Provider Business Practice Location Address
First Line	:	3135 PEOPLES ST STE 404
Second Line	:
City	:	JOHNSON CITY
State	:	TN
Zip	:	37604-4138
Country	:	US
Telephone Number	:	423-454-1006
Fax Number	:	423-328-7825

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/22/2020
Last Update Date	:	05/05/2022

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Directions to “ DR. ASHTON GRACE DOUGLAS PT, DPT, ATC” Practice Location

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