Provider Demographics
NPI:1578542759
Name:JOHNSEN, ERIC MERRIMAN (MD)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:MERRIMAN
Last Name:JOHNSEN
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 1:1007 N 6TH ST
Mailing Address - Street 2:
Mailing Address - City:ALBEMARLE
Mailing Address - State:NC
Mailing Address - Zip Code:28001-3551
Mailing Address - Country:US
Mailing Address - Phone:704-983-3121
Mailing Address - Fax:704-983-4659
Practice Address - Street 1:1007 N 6TH ST
Practice Address - Street 2:
Practice Address - City:ALBEMARLE
Practice Address - State:NC
Practice Address - Zip Code:28001-3551
Practice Address - Country:US
Practice Address - Phone:704-983-3121
Practice Address - Fax:704-983-4659
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-16
Last Update Date:2016-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC24425207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC890243CMedicaid
NC080077493OtherRAILROAD MEDICARE
1171Medicare PIN
NCC81225Medicare UPIN
NC0372050001Medicare NSC