Provider Demographics
NPI:1831110279
Name:JOHNSON, BERNICE IK-JANG MI (PHYISICAN ASSISTANT)
Entity Type:Individual
Prefix:MRS
First Name:BERNICE
Middle Name:IK-JANG MI
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PHYISICAN ASSISTANT
Other - Prefix:MRS
Other - First Name:BERNICE
Other - Middle Name:IK-JANG MI
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHYSICIAN ASSISTANT
Mailing Address - Street 1:7300 W COLLEGE DR
Mailing Address - Street 2:1NW
Mailing Address - City:PALOS HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60463-1152
Mailing Address - Country:US
Mailing Address - Phone:708-671-1374
Mailing Address - Fax:708-671-1378
Practice Address - Street 1:7300 W COLLEGE DR
Practice Address - Street 2:1NW
Practice Address - City:PALOS HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60463-1152
Practice Address - Country:US
Practice Address - Phone:708-671-1374
Practice Address - Fax:708-671-1378
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2013-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085-001948363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL2485011Medicare PIN
363AM0700XMedicare UPIN