MEDICARE: RICKY JOHNSON M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RP1001X	Pulmonary Disease Physician	036072599	IL

General Provider Information

NPI Number	:	1346340650
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RICKY JOHNSON M.D.

Provider Business Mailing Address
First Line	:	170 TERRACE DR
Second Line	:
City	:	CHICAGO HEIGHTS
State	:	IL
Zip	:	60411-1044
Country	:	US
Telephone Number	:	708-754-7725
Fax Number	:

Provider Business Practice Location Address
First Line	:	2011 E 75TH ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60649-3607
Country	:	US
Telephone Number	:	773-752-7796
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/25/2006
Last Update Date	:	07/08/2007

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