Provider Demographics
NPI:1447206677
Name:LIN, JOHNNY L (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHNNY
Middle Name:L
Last Name:LIN
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 1:1 WESTBROOK CORPORATE CTR
Mailing Address - Street 2:#240
Mailing Address - City:WESTCHESTER
Mailing Address - State:IL
Mailing Address - Zip Code:60154-5701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1611 W HARRISON ST # 400
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-4861
Practice Address - Country:US
Practice Address - Phone:312-243-4244
Practice Address - Fax:312-942-1517
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2013-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036115264207XX0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0004XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryFoot and Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036115264 1Medicaid
IL207067OtherMEDICARE PTAN NUMBER LOCALITY #16
ILDA4902OtherRR MEDICARE PTAN NUMBER
IL7686873OtherAETNA
IL207073OtherMEDICARE PTAN NUMBER LOCALITY #15
ILP00381332OtherRR MEDICARE PROVIDER NUMBER
IL207073OtherMEDICARE PTAN NUMBER LOCALITY #15
ILI34577Medicare UPIN
ILK27926Medicare PIN