1275574766 NPI number — MILLISAUN JOHNSON M.D.

Table of content: MILLISAUN JOHNSON M.D. (NPI 1275574766)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275574766 NPI number — MILLISAUN JOHNSON M.D.

Organization/Personal Information

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

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:
1275574766
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/13/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
408 BERGEN AVE
Provider Second Line Business Mailing Address:
JERSEY CITY
Provider Business Mailing Address City Name:
JERSEY CITY
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07304-2202
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
201-451-5137
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
408 BERGEN AVE
Provider Second Line Business Practice Location Address:
JERSEY CITY
Provider Business Practice Location Address City Name:
JERSEY CITY
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07304
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
201-451-5137
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/08/2006

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:  MD426038 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208M00000X , with the licence number: MD426038 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1872726 . This is a "HIGHMARK BLUE SHIELD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 30034506 . This is a "KEYSTONE MERCY" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 1016568100002 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2732298000 . This is a "KEYSTONE IBC" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 34936 . This is a "HEALTH PARTNERS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 101656810-01 . This is a "AMERICHOICE-TC" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 1016568100001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 34937 . This is a "HEALTH PARTNERS - BUCKS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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