1548331333 NPI number — JOHNSTON FAMILY MEDICINE, PA

Table of content: (NPI 1548331333)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548331333 NPI number — JOHNSTON FAMILY MEDICINE, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JOHNSTON FAMILY MEDICINE, PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1548331333
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/21/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
713 WILKINS ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SMITHFIELD
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27577-4647
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-934-1211
Provider Business Mailing Address Fax Number:
919-989-8189

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
713 WILKINS ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SMITHFIELD
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27577
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-934-1211
Provider Business Practice Location Address Fax Number:
919-989-8189
Provider Enumeration Date:
11/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WATSON
Authorized Official First Name:
RENEE
Authorized Official Middle Name:
GODWIN
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
919-934-1211

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  9601754 ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 8902003 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 02003 . This is a "BCBS GRP" identifier . This identifiers is of the category "OTHER".




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