Provider Demographics
NPI:1720214034
Name:JOHNSON MEDICAL SPECIALISTS, PC
Entity Type:Organization
Organization Name:JOHNSON MEDICAL SPECIALISTS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:BIZILJ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:860-684-8125
Mailing Address - Street 1:201 CHESTNUT HILL RD
Mailing Address - Street 2:
Mailing Address - City:STAFFORD SPRINGS
Mailing Address - State:CT
Mailing Address - Zip Code:06076-4005
Mailing Address - Country:US
Mailing Address - Phone:860-684-8415
Mailing Address - Fax:
Practice Address - Street 1:201 CHESTNUT HILL RD
Practice Address - Street 2:ATTN: LORI LADUE
Practice Address - City:STAFFORD SPRINGS
Practice Address - State:CT
Practice Address - Zip Code:06076-4005
Practice Address - Country:US
Practice Address - Phone:860-684-8415
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-02
Last Update Date:2009-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTD100000258OtherMEDICARE PTAN