1770547267 NPI number — LORIE N. JOHNSON MD

Table of content: GRAHAM KEIR (NPI 1194212852)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770547267 NPI number — LORIE N. JOHNSON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JOHNSON
Provider First Name:
LORIE
Provider Middle Name:
N.
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:
1770547267
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/31/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 263
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOCUST GROVE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30248-0263
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
678-429-8146
Provider Business Mailing Address Fax Number:
770-288-8642

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3976 HIGHWAY 42
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOCUST GROVE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30248-4104
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
678-429-8146
Provider Business Practice Location Address Fax Number:
678-814-4708
Provider Enumeration Date:
04/13/2006

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: 207V00000X , with the licence number:  MD419112L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207V00000X , with the licence number: 62054 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0019726940005 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0019726940001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 653434213B , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1523078 . This is a "BLUE SHIELD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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