Provider Demographics
NPI:1427228758
Name:MILES D. JOHNSON, M.D.P.C.
Entity Type:Organization
Organization Name:MILES D. JOHNSON, M.D.P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MILES
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MDPC
Authorized Official - Phone:678-556-9460
Mailing Address - Street 1:3001 S COBB DR SE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:SMYRNA
Mailing Address - State:GA
Mailing Address - Zip Code:30080-7809
Mailing Address - Country:US
Mailing Address - Phone:678-556-9460
Mailing Address - Fax:678-556-9460
Practice Address - Street 1:150 FIDDLERS RDG
Practice Address - Street 2:
Practice Address - City:FAIRBURN
Practice Address - State:GA
Practice Address - Zip Code:30213-3484
Practice Address - Country:US
Practice Address - Phone:678-556-9460
Practice Address - Fax:678-556-9462
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-03
Last Update Date:2008-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA038817314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP4644Medicare PIN
GAF88377Medicare UPIN