MEDICARE: JOHNSON MEDICAL AND AESTHETICS

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	208D00000X	General Practice Physician	064997	GA

General Provider Information

NPI Number	:	1659748333
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JOHNSON MEDICAL AND AESTHETICS

Provider Business Mailing Address
First Line	:	5500 FREDERICA RD
Second Line	:	SUITE 2202
City	:	SAINT SIMONS ISLAND
State	:	GA
Zip	:	31522-9710
Country	:	US
Telephone Number	:	912-580-1551
Fax Number	:

Provider Business Practice Location Address
First Line	:	5500 FREDERICA RD
Second Line	:	SUITE 2202
City	:	SAINT SIMONS ISLAND
State	:	GA
Zip	:	31522-9710
Country	:	US
Telephone Number	:	912-580-1551
Fax Number	:

Authorized Official
Title or Position	:	CHIEF OFFICER
Name	:	DR. WILLIAM JOHNSON
Credential	:	M.D.
Telephone Number	:	912-580-1516

Provider Enumeration Date	:	08/28/2015
Last Update Date	:	08/28/2015

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