1679581227 NPI number — SUSAN L JOHNSON MD

Table of content: SUSAN L JOHNSON MD (NPI 1679581227)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679581227 NPI number — SUSAN L JOHNSON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JOHNSON
Provider First Name:
SUSAN
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SMITH
Provider Other First Name:
SUSAN
Provider Other Middle Name:
L
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1679581227
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8055 O ST
Provider Second Line Business Mailing Address:
STE 300
Provider Business Mailing Address City Name:
LINCOLN
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
68510-2580
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
402-421-0896
Provider Business Mailing Address Fax Number:
402-421-0945

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2200 S 40TH ST
Provider Second Line Business Practice Location Address:
STE 104
Provider Business Practice Location Address City Name:
LINCOLN
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68506-2407
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
402-483-6000
Provider Business Practice Location Address Fax Number:
402-483-6106
Provider Enumeration Date:
08/03/2006

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: 207Q00000X , with the licence number:  16056 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 35833 . This is a "BCBS" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".
  • Identifier: 01-00145 . This is a "UHC" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".
  • Identifier: 1208 . This is a "MIDLAND'S CHOICE" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".
  • Identifier: 470780857 32 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".




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