Healthcare Provider Details

I. General information

NPI: 1114374287
Provider Name (Legal Business Name): MICHAEL JOHNSON SA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/19/2016
Last Update Date: 07/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2886 SANDY PLAINS RD
MARIETTA GA
30066-0240
US

IV. Provider business mailing address

2886 SANDY PLAINS RD
MARIETTA GA
30066-0240
US

V. Phone/Fax

Practice location:
  • Phone: 404-436-0664
  • Fax: 404-393-6142
Mailing address:
  • Phone: 404-436-0664
  • Fax: 404-393-4162

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number16-399
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: