MEDICARE: NATHAN SAMUEL JOHNSON MD

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	207L00000X	Anesthesiology Physician	01072715A	IN
2	390200000X	Student in an Organized Health Care Education/Training Program	11015540A	IN

General Provider Information

NPI Number	:	1841510245
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NATHAN SAMUEL JOHNSON MD

Provider Business Mailing Address
First Line	:	6009 RALSTON AVE
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46220-2353
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6009 RALSTON AVE
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46220-2353
Country	:	US
Telephone Number	:	219-916-6883
Fax Number	:

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

Provider Enumeration Date	:	06/08/2010
Last Update Date	:	05/20/2014

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