1861589723 NPI number — MARY SUSAN JOHNSON P.T.

Table of content: MARY SUSAN JOHNSON P.T. (NPI 1861589723)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861589723 NPI number — MARY SUSAN JOHNSON P.T.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JOHNSON
Provider First Name:
MARY
Provider Middle Name:
SUSAN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
P.T.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
JOHNSON
Provider Other First Name:
MARY
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
P.T.
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1861589723
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/05/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3048 MOMENTUM PL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60689-5330
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
262-657-0222
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
18000 W BLUEMOUND RD STE P
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BROOKFIELD
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53045-2931
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
262-879-0010
Provider Business Practice Location Address Fax Number:
262-879-9781
Provider Enumeration Date:
10/10/2006

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: 225100000X , with the licence number:  3796 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2002030008 . This is a "ANTHEM BCBS PROVIDER NUMBER" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 3796-024 . This is a "STATE OF WI PHYSICAL THERAPY LICENSE NUMBER" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 83388002 . This is a "PTAN" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".




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