1750606075 NPI number — SUSANNAH E JOHNSON MD

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750606075 NPI number — SUSANNAH E JOHNSON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JOHNSON
Provider First Name:
SUSANNAH
Provider Middle Name:
E
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:
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:
1750606075
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/13/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 68
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
POLLOCKSVILLE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28573-0068
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
252-638-4023
Provider Business Mailing Address Fax Number:
252-633-2833

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2604 DR MARTIN LUTHER KING JR BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEW BERN
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28562-4238
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
252-638-4023
Provider Business Practice Location Address Fax Number:
252-633-2833
Provider Enumeration Date:
03/30/2010

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:  50503 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208M00000X , with the licence number: 50503 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: 2021-01038 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 7100265170 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: Q001805 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 6002116 . This is a "BLUECROSS BLUESHIELD" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 6010882 . This is a "BLUE CROSS-BLUE SHIELD" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com