1205474780 NPI number — ANDERS CHRISTEN JOHNSON

Table of content: ANDERS CHRISTEN JOHNSON (NPI 1205474780)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205474780 NPI number — ANDERS CHRISTEN JOHNSON

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JOHNSON
Provider First Name:
ANDERS
Provider Middle Name:
CHRISTEN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
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:
1205474780
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/27/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12780 CONESTOGA WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOLO
Provider Business Mailing Address State Name:
MT
Provider Business Mailing Address Postal Code:
59847-8475
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
406-544-6089
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
301 MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STEVENSVILLE
Provider Business Practice Location Address State Name:
MT
Provider Business Practice Location Address Postal Code:
59870-2597
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
406-777-5591
Provider Business Practice Location Address Fax Number:
406-777-5451
Provider Enumeration Date:
12/16/2019

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: 183500000X , with the licence number:  3962 , registered in the state of MT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 81-1193183 , issued by the state of ( MT ) . This identifiers is of the category "MEDICAID".




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