Provider Demographics
NPI:1134276934
Name:JOHNSON-HOOPER, TISA M (MD)
Entity type:Individual
Prefix:
First Name:TISA
Middle Name:M
Last Name:JOHNSON-HOOPER
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:HENRY FORD HEALTH SYSTEM
Mailing Address - Street 2:3031 WEST GRAND BLVD.
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202
Mailing Address - Country:US
Mailing Address - Phone:313-916-2454
Mailing Address - Fax:
Practice Address - Street 1:HENRY FORD HEALTH SYSTEM
Practice Address - Street 2:3031 WEST GRAND BLVD.
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202
Practice Address - Country:US
Practice Address - Phone:313-916-2454
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2021-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301075433208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TJ075433OtherCHAMPUS-CHAMPUS
MI418507510Medicaid
TJ075433OtherCOMMERCIAL-COMMERCIAL NUMBER
700H262280OtherBLUE CROSS-BLUE CROSS
700H262280OtherBLUE CROSS-BLUE CROSS
0H26228292Medicare ID - Type Unspecified