Provider Demographics
NPI:1639429350
Name:JOHNSON, JAMES EUGENE (PHYSICAL THERAPIST)
Entity Type:Individual
Prefix:MR
First Name:JAMES
Middle Name:EUGENE
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:409 NW 9TH AVE
Mailing Address - Street 2:MERCER COUNTY HOSPITAL
Mailing Address - City:ALEDO
Mailing Address - State:IL
Mailing Address - Zip Code:61231-1258
Mailing Address - Country:US
Mailing Address - Phone:309-582-5301
Mailing Address - Fax:309-582-3737
Practice Address - Street 1:409 NW 9TH AVE
Practice Address - Street 2:
Practice Address - City:ALEDO
Practice Address - State:IL
Practice Address - Zip Code:61231-1258
Practice Address - Country:US
Practice Address - Phone:309-582-5301
Practice Address - Fax:309-582-3737
Is Sole Proprietor?:No
Enumeration Date:2012-09-11
Last Update Date:2012-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.002597225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL366007544001Medicaid
IL366007544401Medicaid
IL366007544001Medicaid
IL141304Medicare PIN
IL142304Medicare PIN
IL141304Medicare Oscar/Certification