1295788388 NPI number — GEORGE 'BRICK' RETER JOHNSTONE PHD

Table of content: GEORGE 'BRICK' RETER JOHNSTONE PHD (NPI 1295788388)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295788388 NPI number — GEORGE 'BRICK' RETER JOHNSTONE PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JOHNSTONE
Provider First Name:
GEORGE
Provider Middle Name:
'BRICK' RETER
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PHD
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:
1295788388
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/03/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2020 PEACHTREE RD NW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30309-1426
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-367-1208
Provider Business Mailing Address Fax Number:
404-603-4441

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
115 BUSINESS LOOP 70 W
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COLUMBIA
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65203-3244
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-882-1561
Provider Business Practice Location Address Fax Number:
573-884-1889
Provider Enumeration Date:
05/18/2006

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: 103T00000X , with the licence number:  PSY004549 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 103TC0700X , with the licence number: PYR0266 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 131610 . This is a "HEALTHLINK" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 6145989 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 680002939 . This is a "RR MEDICARE" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 13644 . This is a "BLUE SHIELD/BLUE CHOICE" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 493401103 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




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