Provider Demographics
NPI:1467535799
Name:BRIAN A JOHNSON MD PC
Entity Type:Organization
Organization Name:BRIAN A JOHNSON MD PC
Other - Org Name:BRIAN A JOHNSON MD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGED CARE SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:DIRENDIA
Authorized Official - Middle Name:
Authorized Official - Last Name:SHACKELFORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:800-654-0889
Mailing Address - Street 1:613 TERRACE DR
Mailing Address - Street 2:
Mailing Address - City:WINAMAC
Mailing Address - State:IN
Mailing Address - Zip Code:46996-1111
Mailing Address - Country:US
Mailing Address - Phone:574-946-6644
Mailing Address - Fax:
Practice Address - Street 1:613 TERRACE DR
Practice Address - Street 2:
Practice Address - City:WINAMAC
Practice Address - State:IN
Practice Address - Zip Code:46996-1111
Practice Address - Country:US
Practice Address - Phone:574-946-6644
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-23
Last Update Date:2008-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN5003424A332900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site
Provider Identifiers
StateIdentifier IDID TypeIssuer
1535561OtherOTHER ID NUMBER-COMMERCIAL NUMBER
IN100210710Medicaid