1710031117 NPI number — DR. MARY J JOHNSON DC

Table of content: DR. MARY J JOHNSON DC (NPI 1710031117)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710031117 NPI number — DR. MARY J JOHNSON DC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JOHNSON
Provider First Name:
MARY
Provider Middle Name:
J
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DC
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:
1710031117
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/10/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
23624 ST. FRANCIS BLVD., STE #1
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ST FRANCIS
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55070
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
763-753-3126
Provider Business Mailing Address Fax Number:
763-753-2808

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
23624 ST FRANCIS BLVD
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
ST FRANCIS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55070-0399
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
763-753-3126
Provider Business Practice Location Address Fax Number:
763-753-2808
Provider Enumeration Date:
01/22/2007

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 , with the licence number:  2663 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 231258 . This is a "CCMI" identifier . This identifiers is of the category "OTHER".
  • Identifier: 4K009J0 . This is a "BCBS INDIVIDUAL" identifier . This identifiers is of the category "OTHER".
  • Identifier: 4K008J0 . This is a "BCBS CLINIC" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0125 . This is a "HSM" identifier . This identifiers is of the category "OTHER".
  • Identifier: 4440078 . This is a "MEDICA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 817228500 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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