=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144475831
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUTH WEST MICHIGAN UROLOGY PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/21/2008
-----------------------------------------------------
Last Update Date | 12/18/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 551 LINN ST SUITE # 20
-----------------------------------------------------
City | ALLEGAN
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49010-1595
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 268-686-5863
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 551 LINN ST SUITE # 20
-----------------------------------------------------
City | ALLEGAN
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49010-1595
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 268-686-5863
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | OLIVER L JOHNSTON
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 269-686-5863
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208800000X
-----------------------------------------------------
Taxonomy Name | Urology Physician
-----------------------------------------------------
License Number | 2075205
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------