Provider Demographics
NPI:1396934659
Name:SIDNEY P JOHNSON, M.D. P.C
Entity type:Organization
Organization Name:SIDNEY P JOHNSON, M.D. P.C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INSURANCE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:PHYLLIS
Authorized Official - Middle Name:
Authorized Official - Last Name:GRIFFIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-375-2521
Mailing Address - Street 1:PO BOX 787
Mailing Address - Street 2:
Mailing Address - City:HAZLEHURST
Mailing Address - State:GA
Mailing Address - Zip Code:31539-0787
Mailing Address - Country:US
Mailing Address - Phone:912-375-2521
Mailing Address - Fax:912-375-2409
Practice Address - Street 1:11 JOHNSON ST
Practice Address - Street 2:
Practice Address - City:HAZLEHURST
Practice Address - State:GA
Practice Address - Zip Code:31539-6243
Practice Address - Country:US
Practice Address - Phone:912-375-2521
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-23
Last Update Date:2007-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA10971208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00112912AMedicaid
GAE00973Medicare UPIN
GAGRP6738Medicare PIN