Healthcare Provider Details

I. General information

NPI: 1376819870
Provider Name (Legal Business Name): SARAH ELISABETH JOHNSON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2012
Last Update Date: 01/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 WEST DEVON AVE
CHICAGO IL
60660
US

IV. Provider business mailing address

1300 WEST DEVON AVE
CHICAGO IL
60660
US

V. Phone/Fax

Practice location:
  • Phone: 773-751-7850
  • Fax: 773-751-7855
Mailing address:
  • Phone: 773-751-7850
  • Fax: 773-751-7855

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number125062411
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036.136859
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: