Provider Demographics
NPI:1629119177
Name:STEPHANIE M JOHNSON MD LLC
Entity Type:Organization
Organization Name:STEPHANIE M JOHNSON MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE EMPLOYEE
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:812-522-9761
Mailing Address - Street 1:274 HANNAH AVE
Mailing Address - Street 2:
Mailing Address - City:SEYMOUR
Mailing Address - State:IN
Mailing Address - Zip Code:47274-4058
Mailing Address - Country:US
Mailing Address - Phone:812-522-9761
Mailing Address - Fax:812-522-9761
Practice Address - Street 1:274 HANNAH AVE
Practice Address - Street 2:
Practice Address - City:SEYMOUR
Practice Address - State:IN
Practice Address - Zip Code:47274-4058
Practice Address - Country:US
Practice Address - Phone:812-522-9761
Practice Address - Fax:812-522-9761
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01054624A207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
INH51076Medicare UPIN