Provider Demographics
NPI:1225104664
Name:JOHNSON, RANDALL S (PT)
Entity Type:Individual
Prefix:MR
First Name:RANDALL
Middle Name:S
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 MEADOW VIEW RD
Mailing Address - Street 2:SUITE 4
Mailing Address - City:BRISTOL
Mailing Address - State:TN
Mailing Address - Zip Code:37620-1725
Mailing Address - Country:US
Mailing Address - Phone:423-844-6935
Mailing Address - Fax:423-844-6937
Practice Address - Street 1:105 MEADOW VIEW RD
Practice Address - Street 2:SUITE 4
Practice Address - City:BRISTOL
Practice Address - State:TN
Practice Address - Zip Code:37620-1725
Practice Address - Country:US
Practice Address - Phone:423-844-6935
Practice Address - Fax:423-844-6937
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2010-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN13492251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN103I650212Medicare PIN