Healthcare Provider Details

I. General information

NPI: 1184665630
Provider Name (Legal Business Name): MICHAEL BRIAN TILL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2006
Last Update Date: 11/28/2022
Certification Date: 11/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 HAMPTON POINT DR
ST AUGUSTINE FL
32092-3063
US

IV. Provider business mailing address

PO BOX 746638
ATLANTA GA
30374-6638
US

V. Phone/Fax

Practice location:
  • Phone: 904-484-7772
  • Fax: 904-390-7437
Mailing address:
  • Phone: 904-202-1032
  • Fax: 904-376-4107

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME 88768
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: