Provider Demographics
NPI:1497031827
Name:JOHNSTON SPECIALTY PHYSICIAN SERVICES, INC.
Entity Type:Organization
Organization Name:JOHNSTON SPECIALTY PHYSICIAN SERVICES, INC.
Other - Org Name:JOHNSTON MEDICAL ASSOCIATES GASTROENTEROLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TRACEY
Authorized Official - Middle Name:
Authorized Official - Last Name:WOODRUFF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-938-7182
Mailing Address - Street 1:PO BOX 63366
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28263-3366
Mailing Address - Country:US
Mailing Address - Phone:866-430-0564
Mailing Address - Fax:919-967-6647
Practice Address - Street 1:514 N BRIGHTLEAF BLVD
Practice Address - Street 2:SUITE 1610
Practice Address - City:SMITHFIELD
Practice Address - State:NC
Practice Address - Zip Code:27577-4407
Practice Address - Country:US
Practice Address - Phone:919-938-7182
Practice Address - Fax:919-938-7185
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-31
Last Update Date:2011-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty