Healthcare Provider Details

I. General information

NPI: 1285686741
Provider Name (Legal Business Name): TIMOTHY ALLEN JOHNSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2006
Last Update Date: 03/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 HOBART ST
CADILLAC MI
49601-2331
US

IV. Provider business mailing address

6550 SOLUTIONS CTR
CHICAGO IL
60677-6005
US

V. Phone/Fax

Practice location:
  • Phone: 231-876-7200
  • Fax:
Mailing address:
  • Phone: 231-759-5089
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number4301079025
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: