Provider Demographics
NPI:1710902127
Name:JOHNSON, PHILIP B (MD)
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:B
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 W. PARK ST.
Mailing Address - Street 2:BWPC
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61801-2500
Mailing Address - Country:US
Mailing Address - Phone:217-383-6792
Mailing Address - Fax:
Practice Address - Street 1:1818 E. WINDSOR ROAD
Practice Address - Street 2:ADULT MEDICINE/GERIATRICS
Practice Address - City:URBANA
Practice Address - State:IL
Practice Address - Zip Code:61802
Practice Address - Country:US
Practice Address - Phone:217-255-9646
Practice Address - Fax:217-326-1777
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2015-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036044383207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL110062458OtherRAILROAD
IL0533210001OtherDMERC
ILC48205Medicare UPIN
IL110062458OtherRAILROAD
ILIL3270505Medicare PIN
IL0533210001OtherDMERC