1063500866 NPI number — DR. WILLIAM GEORGE JOHNSON DC

Table of content: DR. WILLIAM GEORGE JOHNSON DC (NPI 1063500866)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063500866 NPI number — DR. WILLIAM GEORGE JOHNSON DC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JOHNSON
Provider First Name:
WILLIAM
Provider Middle Name:
GEORGE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DC
Provider Gender Code:
M

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:
1063500866
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/05/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 413
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WINNEBAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61088-0413
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
815-335-2820
Provider Business Mailing Address Fax Number:
815-335-2009

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
502 N ELIDA ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WINNEBAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61088-8946
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-335-2820
Provider Business Practice Location Address Fax Number:
815-335-2009
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: 111N00000X , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0010182024 . This is a "BLUE CROSS M& BLUE SHIELD" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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