Provider Demographics
NPI:1831136027
Name:JOHANSSON, KRISTER M (MD)
Entity Type:Individual
Prefix:
First Name:KRISTER
Middle Name:M
Last Name:JOHANSSON
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 1:5215 N CALIFORNIA AVE
Mailing Address - Street 2:SUITE 604
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625-7014
Mailing Address - Country:US
Mailing Address - Phone:773-878-3627
Mailing Address - Fax:773-293-8824
Practice Address - Street 1:5215 N CALIFORNIA AVE
Practice Address - Street 2:SUITE 604
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60625-7014
Practice Address - Country:US
Practice Address - Phone:773-878-3627
Practice Address - Fax:773-293-8824
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2021-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036101307207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036101307Medicaid
ILK27293Medicare ID - Type Unspecified
H29820Medicare UPIN