Healthcare Provider Details

I. General information

NPI: 1689658973
Provider Name (Legal Business Name): JOEL A JOHNSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/01/2005
Last Update Date: 04/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 LAKESHORE DR.
ISHPEMING MI
49849
US

IV. Provider business mailing address

901 LAKESHORE DR
ISHPEMING MI
49849
US

V. Phone/Fax

Practice location:
  • Phone: 906-485-2696
  • Fax: 906-485-2728
Mailing address:
  • Phone: 906-485-2696
  • Fax: 906-485-2728

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number4301057398
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: