MEDICARE: ANDREW ROBERT JOHNSON M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208600000X	Surgery Physician	28808	MS
2	208600000X	Surgery Physician	036121708	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1164418943
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANDREW ROBERT JOHNSON M.D.

Provider Business Mailing Address
First Line	:	4218 LINCOLNSHIRE DR
Second Line	:	PO BOX 968
City	:	MOUNT VERNON
State	:	IL
Zip	:	62864-2156
Country	:	US
Telephone Number	:	618-242-8480
Fax Number	:	618-242-8499

Provider Business Practice Location Address
First Line	:	4218 LINCOLNSHIRE DR
Second Line	:
City	:	MOUNT VERNON
State	:	IL
Zip	:	62864-2156
Country	:	US
Telephone Number	:	618-242-8480
Fax Number	:	618-242-8499

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/27/2005
Last Update Date	:	10/11/2022

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