Provider Demographics
NPI:1508861345
Name:JOHNSON, JOHN KIM (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:KIM
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1 INDEPENDENCE PT
Mailing Address - Street 2:SUITE 212
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-4566
Mailing Address - Country:US
Mailing Address - Phone:864-797-6044
Mailing Address - Fax:864-797-6198
Practice Address - Street 1:200 PATEWOOD DR
Practice Address - Street 2:SUITE B260
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-3593
Practice Address - Country:US
Practice Address - Phone:864-454-4600
Practice Address - Fax:864-464-4605
Is Sole Proprietor?:No
Enumeration Date:2005-06-17
Last Update Date:2011-05-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
SC12867207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCP00318488OtherRR MEDICARE
SCP00801293OtherRR MEDICARE
SC128677Medicaid
SC576007863180OtherBCBS OF SC
SCC019506904Medicare PIN
SCP00318488OtherRR MEDICARE
SCC019507951Medicare PIN