Provider Demographics
NPI:1760562268
Name:BENJAMIN MAYS JOHNSTON, SR, M.D.
Entity Type:Organization
Organization Name:BENJAMIN MAYS JOHNSTON, SR, M.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING AGENT
Authorized Official - Prefix:
Authorized Official - First Name:TAMMY
Authorized Official - Middle Name:J
Authorized Official - Last Name:BRICKLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:478-254-5943
Mailing Address - Street 1:PO BOX 28170
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31221-8170
Mailing Address - Country:US
Mailing Address - Phone:478-254-5943
Mailing Address - Fax:478-254-6093
Practice Address - Street 1:900 FIRST STREET
Practice Address - Street 2:SUITE B
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-6806
Practice Address - Country:US
Practice Address - Phone:478-746-1717
Practice Address - Fax:478-738-8639
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BENJAMIN M. JOHNSTON, JR, M.D.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-17
Last Update Date:2010-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA018579207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DD7073OtherRAILROAD MEDICARE
GADD7073OtherMEDICARE RAILROAD
GAGRP7362Medicare PIN