MEDICARE: JON MICHAEL PRESTON M.S.P.T.

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	PT006667	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	7480721	OTHER	GA	AETNA PPO POS PIN
2	9406564	OTHER	GA	PHCS PIN
3	52068657-004	OTHER	GA	BCBSGA PROVIDER NUMBER

General Provider Information

NPI Number	:	1518024991
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JON MICHAEL PRESTON M.S.P.T.

Provider Business Mailing Address
First Line	:	2557 COLLINS PORT CV
Second Line	:
City	:	SUWANEE
State	:	GA
Zip	:	30024-2787
Country	:	US
Telephone Number	:	770-232-7100
Fax Number	:	770-232-7198

Provider Business Practice Location Address
First Line	:	1810 PEACHTREE INDUSTRIAL BLVD
Second Line	:	SUITE 130
City	:	DULUTH
State	:	GA
Zip	:	30097-8180
Country	:	US
Telephone Number	:	770-232-7100
Fax Number	:	770-232-7198

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

Provider Enumeration Date	:	01/03/2007
Last Update Date	:	07/09/2007

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