Provider Demographics
NPI:1831203512
Name:STACEY M JOHNSON MD PA
Entity type:Organization
Organization Name:STACEY M JOHNSON MD PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:COO VP OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:PETE
Authorized Official - Middle Name:
Authorized Official - Last Name:ROSS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-425-6212
Mailing Address - Street 1:# 17 MEDICAL PLAZA
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:AR
Mailing Address - Zip Code:72653
Mailing Address - Country:US
Mailing Address - Phone:870-425-6212
Mailing Address - Fax:870-424-3774
Practice Address - Street 1:# 17 MEDICAL PLAZA
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME
Practice Address - State:AR
Practice Address - Zip Code:72653
Practice Address - Country:US
Practice Address - Phone:870-425-6212
Practice Address - Fax:870-424-3774
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-18
Last Update Date:2008-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARR2724174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR111814002Medicaid
AR57598OtherAR BCBS PROV
AR57598Medicare ID - Type UnspecifiedMEDICARE PROVIDER #