MEDICARE: JOHN MICHAEL DOROUGH AA

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	363A00000X	Physician Assistant	001777	GA
2	367H00000X	Anesthesiologist Assistant	AA91	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	P00410144	OTHER	GA	RRB

General Provider Information

NPI Number	:	1063460236
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHN MICHAEL DOROUGH AA

Provider Business Mailing Address
First Line	:	161 RAYMONDS GRANT TRCE
Second Line	:
City	:	SAINT SIMONS ISLAND
State	:	GA
Zip	:	31522-5393
Country	:	US
Telephone Number	:	912-571-0808
Fax Number	:

Provider Business Practice Location Address
First Line	:	161 RAYMONDS GRANT TRCE
Second Line	:
City	:	SAINT SIMONS ISLAND
State	:	GA
Zip	:	31522-5393
Country	:	US
Telephone Number	:	912-638-9734
Fax Number	:

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

Provider Enumeration Date	:	05/04/2006
Last Update Date	:	07/31/2013

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Directions to “ JOHN MICHAEL DOROUGH AA” Practice Location

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