Healthcare Provider Details

I. General information

NPI: 1659531903
Provider Name (Legal Business Name): PIERRE MICHAEL JOHNSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2008
Last Update Date: 08/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MEMORIAL DR SUITE 300
DECATUR IL
62526-6303
US

IV. Provider business mailing address

926 MAIN ST APT 209
PEORIA IL
61602-1039
US

V. Phone/Fax

Practice location:
  • Phone: 217-872-2400
  • Fax: 217-875-4680
Mailing address:
  • Phone: 773-354-1659
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number036-132597
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: