Provider Demographics
NPI:1700906583
Name:VAN W. JOHNSON MD PC
Entity Type:Organization
Organization Name:VAN W. JOHNSON MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:NORDIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:814-726-1921
Mailing Address - Street 1:103 W SAINT CLAIR ST
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:PA
Mailing Address - Zip Code:16365-2197
Mailing Address - Country:US
Mailing Address - Phone:814-726-1921
Mailing Address - Fax:814-726-7881
Practice Address - Street 1:103 W SAINT CLAIR ST
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:PA
Practice Address - Zip Code:16365-2197
Practice Address - Country:US
Practice Address - Phone:814-726-1921
Practice Address - Fax:814-726-7881
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD013857E207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA105684OtherBLUE SHIELD INDIVIDUAL
PA1938251OtherBLUE SHIELD GROUP
PAC30224Medicare UPIN
PA1938251OtherBLUE SHIELD GROUP
PA105684OtherBLUE SHIELD INDIVIDUAL