Healthcare Provider Details

I. General information

NPI: 1992887202
Provider Name (Legal Business Name): MICHAEL W JOHNSON, MD, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/19/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 BURDETTE ST
SAINT IGNACE MI
49781-1712
US

IV. Provider business mailing address

101 W MITCHELL ST
PETOSKEY MI
49770-2323
US

V. Phone/Fax

Practice location:
  • Phone: 906-643-0466
  • Fax:
Mailing address:
  • Phone: 231-487-1000
  • Fax: 231-487-1002

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number4301054807
License Number StateMI

VIII. Authorized Official

Name: TINA BAYS
Title or Position: OFFICE MANAGER
Credential:
Phone: 231-487-1000