Healthcare Provider Details

I. General information

NPI: 1407000177
Provider Name (Legal Business Name): CHARLES B JOHNSTON MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2008
Last Update Date: 11/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

675 W NORTH AVE SUITE 202
MELROSE PARK IL
60160-1634
US

IV. Provider business mailing address

PO BOX 379
ORLAND PARK IL
60462-0379
US

V. Phone/Fax

Practice location:
  • Phone: 708-681-7905
  • Fax: 708-460-1117
Mailing address:
  • Phone: 708-460-9833
  • Fax: 708-460-1117

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036078749
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036078749
License Number StateIL

VIII. Authorized Official

Name: DR. CHARLES B JOHNSTON
Title or Position: PRESIDENT
Credential: M.D.
Phone: 708-681-7905