1427296276 NPI number — DR. SAMUEL TERRY JOHNSON JR. M.D.

Table of content: DR. SAMUEL TERRY JOHNSON JR. M.D. (NPI 1427296276)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1427296276 NPI number — DR. SAMUEL TERRY JOHNSON JR. M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JOHNSON
Provider First Name:
SAMUEL
Provider Middle Name:
TERRY
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
JR.
Provider Credential Text:
M.D.
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:
1427296276
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/14/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 720
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOLIVAR
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
38008-0720
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
731-659-3125
Provider Business Mailing Address Fax Number:
731-659-3131

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
629 NUCKOLLS RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOLIVAR
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38008-1599
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
731-658-3388
Provider Business Practice Location Address Fax Number:
731-658-4079
Provider Enumeration Date:
02/02/2009

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: 207Q00000X , with the licence number:  47830 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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