MEDICARE: JILL MARIE JOHNSON D.O.

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	207V00000X	Obstetrics & Gynecology Physician	OS14223	FL
2	207V00000X	Obstetrics & Gynecology Physician	LL1572	SC

General Provider Information

NPI Number	:	1508121948
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JILL MARIE JOHNSON D.O.

Provider Business Mailing Address
First Line	:	460 CLEMSON RD
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29229-7925
Country	:	US
Telephone Number	:	803-438-3800
Fax Number	:	803-438-3898

Provider Business Practice Location Address
First Line	:	460 CLEMSON RD
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29229-7925
Country	:	US
Telephone Number	:	803-438-3800
Fax Number	:	803-438-3898

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

Provider Enumeration Date	:	07/11/2012
Last Update Date	:	07/19/2021

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