MEDICARE: MR. RUSSELL JOHNSON JR. BC-HIS

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	237700000X	Hearing Instrument Specialist	157	SC

General Provider Information

NPI Number	:	1417172966
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. RUSSELL JOHNSON JR. BC-HIS

Provider Business Mailing Address
First Line	:	1522 GREGG ST
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29201-3530
Country	:	US
Telephone Number	:	803-779-2430
Fax Number	:	803-779-3458

Provider Business Practice Location Address
First Line	:	1522 GREGG ST
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29201-3530
Country	:	US
Telephone Number	:	803-779-2430
Fax Number	:	803-779-3458

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

Provider Enumeration Date	:	04/17/2007
Last Update Date	:	12/03/2014

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Directions to “ MR. RUSSELL JOHNSON JR. BC-HIS” Practice Location

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