MEDICARE: KERRY JOHNSON

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	225100000X	Physical Therapist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	70013241	OTHER	IL	LICENSE#

General Provider Information

NPI Number	:	1740316777
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KERRY JOHNSON

Provider Business Mailing Address
First Line	:	3241 N RACINE AVE # 3
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60657-3320
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	201 E HURON ST STE 9-105
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60611-2980
Country	:	US
Telephone Number	:	312-916-3700
Fax Number	:

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

Provider Enumeration Date	:	02/26/2007
Last Update Date	:	07/08/2007

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Directions to “ KERRY JOHNSON ” Practice Location

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