Provider Demographics
NPI:1629078688
Name:RONALD L JOHNSON
Entity Type:Organization
Organization Name:RONALD L JOHNSON
Other - Org Name:WINCHESTER FAMILY PRACTICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:L
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:217-285-9661
Mailing Address - Street 1:231 W CHERRY ST
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:IL
Mailing Address - Zip Code:62694-1027
Mailing Address - Country:US
Mailing Address - Phone:217-742-3117
Mailing Address - Fax:217-742-3988
Practice Address - Street 1:231 W CHERRY ST
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:IL
Practice Address - Zip Code:62694-1027
Practice Address - Country:US
Practice Address - Phone:217-742-3117
Practice Address - Fax:217-742-3988
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL148919261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========002Medicaid
IL=========002Medicaid