Healthcare Provider Details

I. General information

NPI: 1225969892
Provider Name (Legal Business Name): MATTHEW RUSSELL JOHNSOM EMT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/25/2026
Last Update Date: 05/25/2026
Certification Date: 05/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12318 EMPIRE ST
LOVES PARK IL
61111-8957
US

IV. Provider business mailing address

12318 EMPIRE ST
LOVES PARK IL
61111-8957
US

V. Phone/Fax

Practice location:
  • Phone: 815-378-4556
  • Fax:
Mailing address:
  • Phone: 815-378-4556
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code146N00000X
TaxonomyBasic Emergency Medical Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: