Provider Demographics
NPI:1619159290
Name:PHILIP E P JOHNSON
Entity Type:Organization
Organization Name:PHILIP E P JOHNSON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE DIRECTOR SMG
Authorized Official - Prefix:
Authorized Official - First Name:CATHIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MURRAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-659-6537
Mailing Address - Street 1:600 S LAKEVIEW ST
Mailing Address - Street 2:SUITE 104
Mailing Address - City:STURGIS
Mailing Address - State:MI
Mailing Address - Zip Code:49091-2371
Mailing Address - Country:US
Mailing Address - Phone:269-659-4209
Mailing Address - Fax:
Practice Address - Street 1:600 S LAKEVIEW ST
Practice Address - Street 2:SUITE 104
Practice Address - City:STURGIS
Practice Address - State:MI
Practice Address - Zip Code:49091-2371
Practice Address - Country:US
Practice Address - Phone:269-659-4209
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-05
Last Update Date:2007-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0G56212Medicare PIN