Provider Demographics
NPI:1578995619
Name:JOHNSON, MICHAEL (CTRS)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:CTRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:771 MANATAWNA AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19128-1020
Mailing Address - Country:US
Mailing Address - Phone:215-341-1410
Mailing Address - Fax:
Practice Address - Street 1:1930 S BROAD ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19145-2328
Practice Address - Country:US
Practice Address - Phone:215-339-4563
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-31
Last Update Date:2013-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist