1710902127 NPI number — PHILIP B JOHNSON M.D.

Table of content: PHILIP B JOHNSON M.D. (NPI 1710902127)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710902127 NPI number — PHILIP B JOHNSON M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JOHNSON
Provider First Name:
PHILIP
Provider Middle Name:
B
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1710902127
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/26/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
611 W. PARK ST.
Provider Second Line Business Mailing Address:
BWPC
Provider Business Mailing Address City Name:
URBANA
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61801-2500
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
217-383-6792
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1818 E. WINDSOR ROAD
Provider Second Line Business Practice Location Address:
ADULT MEDICINE/GERIATRICS
Provider Business Practice Location Address City Name:
URBANA
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61802
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
217-255-9646
Provider Business Practice Location Address Fax Number:
217-326-1777
Provider Enumeration Date:
07/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  036044383 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 110062458 . This is a "RAILROAD" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 0533210001 . This is a "DMERC" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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