Provider Demographics
NPI:1265457782
Name:JOHNSON, PHELPS BRIAN
Entity Type:Individual
Prefix:
First Name:PHELPS
Middle Name:BRIAN
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:407 E 3RD ST
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55805-1950
Mailing Address - Country:US
Mailing Address - Phone:218-786-4000
Mailing Address - Fax:
Practice Address - Street 1:407 E 3RD ST
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55805-1950
Practice Address - Country:US
Practice Address - Phone:218-786-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2011-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN43180207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN190148600Medicaid
MN930001738Medicare PIN
MN190148600Medicaid