Provider Demographics
NPI:1114374287
Name:JOHNSON, MICHAEL (SA-C)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:SA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2886 SANDY PLAINS RD
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30066-0240
Mailing Address - Country:US
Mailing Address - Phone:404-436-0664
Mailing Address - Fax:404-393-4162
Practice Address - Street 1:2886 SANDY PLAINS RD
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30066-0240
Practice Address - Country:US
Practice Address - Phone:404-436-0664
Practice Address - Fax:404-393-6142
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-19
Last Update Date:2016-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA16-399246ZC0007X
282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant