Provider Demographics
NPI:1407000177
Name:CHARLES B JOHNSTON MD PC
Entity Type:Organization
Organization Name:CHARLES B JOHNSTON MD PC
Other - Org Name:PRIVATE PRACTICE OF RIVER FOREST
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:B
Authorized Official - Last Name:JOHNSTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:708-681-7905
Mailing Address - Street 1:PO BOX 379
Mailing Address - Street 2:
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60462-0379
Mailing Address - Country:US
Mailing Address - Phone:708-460-9833
Mailing Address - Fax:708-460-1117
Practice Address - Street 1:675 W NORTH AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:MELROSE PARK
Practice Address - State:IL
Practice Address - Zip Code:60160-1634
Practice Address - Country:US
Practice Address - Phone:708-681-7905
Practice Address - Fax:708-460-1117
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-07
Last Update Date:2008-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036078749207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL206971Medicare PIN