Healthcare Provider Details

I. General information

NPI: 1780638007
Provider Name (Legal Business Name): SCOTT R JOHNSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2006
Last Update Date: 12/19/2023
Certification Date: 06/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2859 HIGHWAY 45 BYPASS
JACKSON TN
38305-3618
US

IV. Provider business mailing address

PO BOX 400
JACKSON TN
38302-0400
US

V. Phone/Fax

Practice location:
  • Phone: 731-660-8360
  • Fax: 731-660-8377
Mailing address:
  • Phone: 731-423-8697
  • Fax: 731-425-5783

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number46687
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number46687
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: