Healthcare Provider Details

I. General information

NPI: 1326065962
Provider Name (Legal Business Name): ALAN JOHNSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MEMORIAL DR
ALTON IL
62002-6722
US

IV. Provider business mailing address

2 GREYSTOKE CT
BALLWIN MO
63021-4440
US

V. Phone/Fax

Practice location:
  • Phone: 618-463-7311
  • Fax:
Mailing address:
  • Phone: 636-394-1560
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number036-089660
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberMD100153
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: