Provider Demographics
NPI:1336102375
Name:JOHNSON, RUSSELL
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:
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 1:6896 W SNOWVILLE RD
Mailing Address - Street 2:
Mailing Address - City:BRECKSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44141-3214
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2142 N COVE BLVD
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43606-3895
Practice Address - Country:US
Practice Address - Phone:419-291-4101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2008-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34-00-7168207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH727174OtherBCHP
OH000000372951OtherANTHEM
OH341960760035OtherCARESOURCE
OH2228753Medicaid
MI4429949Medicaid
OH810547599042Medicaid
OH000000271437OtherANTHEM
OH810547599042Medicaid
OH2228753Medicaid
OHP00191083Medicare PIN
OH341960760035OtherCARESOURCE