Healthcare Provider Details

I. General information

NPI: 1376837260
Provider Name (Legal Business Name): JOHNSON CLINIC OF COVINGTON, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/08/2011
Last Update Date: 06/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4235 HIGHWAY 51 S
BRIGHTON TN
38011-6921
US

IV. Provider business mailing address

PO BOX 507
COVINGTON TN
38019-0507
US

V. Phone/Fax

Practice location:
  • Phone: 901-475-4752
  • Fax: 901-475-1554
Mailing address:
  • Phone: 901-475-4752
  • Fax: 901-475-1554

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD11374
License Number StateTN

VIII. Authorized Official

Name: DR. SAMUEL T. JOHNSON SR.
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 901-475-4752