1710185376 NPI number — MR. PHILLIP W JOHNSON CPO

Table of content: MR. PHILLIP W JOHNSON CPO (NPI 1710185376)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710185376 NPI number — MR. PHILLIP W JOHNSON CPO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JOHNSON
Provider First Name:
PHILLIP
Provider Middle Name:
W
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
CPO
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:
1710185376
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/21/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3635 S MAIN ST
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
BLACKSBURG
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
24060-7019
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
540-951-2566
Provider Business Mailing Address Fax Number:
540-951-7818

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3635 S MAIN ST
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
BLACKSBURG
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
24060-7019
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
540-951-2566
Provider Business Practice Location Address Fax Number:
540-951-7818
Provider Enumeration Date:
07/05/2007

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: 222Z00000X , with the licence number:  CPO 02395 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 224P00000X , with the licence number: CPO 02395 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 5401900001 . This is a "DMERC MEDICARE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 175522 . This is a "ANTHEM BCBS" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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