Provider Demographics
NPI:1194042499
Name:TERRY JOHNSON
Entity Type:Organization
Organization Name:TERRY JOHNSON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DENISE
Authorized Official - Middle Name:E
Authorized Official - Last Name:BURCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:989-636-7200
Mailing Address - Street 1:5908 EASTMAN AVE
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48640-6748
Mailing Address - Country:US
Mailing Address - Phone:989-636-7200
Mailing Address - Fax:989-636-7210
Practice Address - Street 1:5908 EASTMAN AVE
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48640-6748
Practice Address - Country:US
Practice Address - Phone:989-636-7200
Practice Address - Fax:989-636-7210
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-26
Last Update Date:2022-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002282156FX1800X, 332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1547439Medicaid
MIT33266Medicare UPIN
MI1547439Medicaid
MIOE66504Medicare PIN