1790774255 NPI number — TERRIE M JOHNSON MD

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790774255 NPI number — TERRIE M JOHNSON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JOHNSON
Provider First Name:
TERRIE
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1790774255
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/23/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
900 S PINE ISLAND RD
Provider Second Line Business Mailing Address:
SUITE 800
Provider Business Mailing Address City Name:
PLANTATION
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33324-3920
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
561-863-5757
Provider Business Mailing Address Fax Number:
861-863-6627

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2939 N MILITARY TRL
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WEST PALM BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33409-2916
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
561-863-5757
Provider Business Practice Location Address Fax Number:
561-863-6627
Provider Enumeration Date:
10/18/2005

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: 208000000X , with the licence number:  ME87569 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 291325 . This is a "AVMED" identifier . This identifiers is of the category "OTHER".
  • Identifier: 5720771 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 268732100 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 82186 . This is a "BLUECROSS BLUESHIELD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 268732100 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com