Provider Demographics
NPI: | 1821209800 |
---|---|
Name: | JOHNSON, JENNIFER BEDELL (MD) |
Entity Type: | Individual |
Prefix: | |
First Name: | JENNIFER |
Middle Name: | BEDELL |
Last Name: | JOHNSON |
Suffix: | |
Gender: | F |
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: | 11 MOUNT PARAN RD NE |
Mailing Address - Street 2: | |
Mailing Address - City: | ATLANTA |
Mailing Address - State: | GA |
Mailing Address - Zip Code: | 30342-2209 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 678-312-2470 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 1000 MEDICAL CENTER BLVD |
Practice Address - Street 2: | RADIOLOGY DEPARTMENT |
Practice Address - City: | LAWRENCEVILLE |
Practice Address - State: | GA |
Practice Address - Zip Code: | 30045-7694 |
Practice Address - Country: | US |
Practice Address - Phone: | 770-995-4321 |
Practice Address - Fax: | |
Is Sole Proprietor?: | No |
Enumeration Date: | 2007-05-24 |
Last Update Date: | 2023-07-17 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
GA | 55604 | 2085R0202X |
MS | 14726 | 2085R0202X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 2085R0202X | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
MS | P01194854 | Other | RAILROAD MEDICARE PTAN |
MS | P01194854 | Other | RAILROAD MEDICARE PTAN |
MS | 302I306270 | Medicare UPIN | |
MS | 302I307038 | Medicare PIN |