Healthcare Provider Details

I. General information

NPI: 1205874476
Provider Name (Legal Business Name): MICHAEL O JOHNSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/02/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 1ST CAPITOL DR
SAINT CHARLES MO
63301-2844
US

IV. Provider business mailing address

1836 LACKLAND HILL PKWY ATTN: CREDENTIALING
SAINT LOUIS MO
63146-3572
US

V. Phone/Fax

Practice location:
  • Phone: 636-947-5000
  • Fax:
Mailing address:
  • Phone: 314-989-0300
  • Fax: 314-810-1399

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License NumberR7N07
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: