Provider Demographics
NPI:1366486458
Name:JOHNSON, KENNETH M (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:M
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 E WISCONSIN AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53202-4815
Mailing Address - Country:US
Mailing Address - Phone:414-290-6720
Mailing Address - Fax:414-290-6755
Practice Address - Street 1:1726 SHAWANO AVE
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54303-3216
Practice Address - Country:US
Practice Address - Phone:414-290-6720
Practice Address - Fax:414-290-6755
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2021-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-078597207P00000X
WI53595-020207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI930106598OtherMEDICARE RAILROAD
WI930080950OtherMEDICARE RAILROAD
MI104161654Medicaid
WI010056900OtherMEDICARE RAILROAD
WI930079989OtherMEDICARE RAILROAD
WI32019000Medicaid
WI930070593OtherMEDICARE RAILROAD
WI930077765OtherMEDICARE RAILROAD
WI0030-71116Medicare ID - Type Unspecified
WI0030-45034Medicare ID - Type Unspecified
WI0024-32350Medicare ID - Type Unspecified
WI010056900OtherMEDICARE RAILROAD
E47106Medicare UPIN
WI0045-68655Medicare ID - Type Unspecified
WI930106598OtherMEDICARE RAILROAD
WI0025-01400Medicare ID - Type Unspecified
WI0015-07660Medicare ID - Type Unspecified
WI0005-17130Medicare ID - Type Unspecified