Provider Demographics
NPI:1457470478
Name:JOHNSON, ADAM (PT, CERT MDT)
Entity Type:Individual
Prefix:MR
First Name:ADAM
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PT, CERT MDT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 W PARK ST
Mailing Address - Street 2:
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61801-2500
Mailing Address - Country:US
Mailing Address - Phone:217-326-2911
Mailing Address - Fax:217-344-8047
Practice Address - Street 1:610 N LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:URBANA
Practice Address - State:IL
Practice Address - Zip Code:61801-2432
Practice Address - Country:US
Practice Address - Phone:217-326-2911
Practice Address - Fax:217-344-8047
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
7216OtherPERSONALCARE PROV ID
IL203OtherBLUE CROSS PROV ID
113326OtherHEALTHLINK PROV ID
IL4117OtherHAMP PROVIDER ID
IL4117OtherHAMP PROVIDER ID