Provider Demographics
NPI:1184665630
Name:TILL, MICHAEL BRIAN (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:BRIAN
Last Name:TILL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 746638
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-6638
Mailing Address - Country:US
Mailing Address - Phone:904-202-1032
Mailing Address - Fax:904-376-4107
Practice Address - Street 1:110 HAMPTON POINT DR
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32092-3063
Practice Address - Country:US
Practice Address - Phone:904-484-7772
Practice Address - Fax:904-390-7437
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-08
Last Update Date:2022-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 88768207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL59-2452553OtherCHAMPUS
FL270480300Medicaid
FL50481OtherBLUE CROSS / BLUE SHIELD
FLP00222162OtherRAIL ROAD MEDICARE
I16601Medicare UPIN
FL50481OtherBLUE CROSS / BLUE SHIELD