MEDICARE: MS. KISHA D JOHNSON MD, CGC

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	170300000X	Genetic Counselor (M.S.)

General Provider Information

NPI Number	:	1194704874
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. KISHA D JOHNSON MD, CGC

Provider Business Mailing Address
First Line	:	3802 W CONGRESS PKWY
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60624-3101
Country	:	US
Telephone Number	:	410-908-0683
Fax Number	:	312-942-2857

Provider Business Practice Location Address
First Line	:	1750 W HARRISON ST
Second Line	:	1507 JELKE
City	:	CHICAGO
State	:	IL
Zip	:	60612-3825
Country	:	US
Telephone Number	:	312-942-6298
Fax Number	:	312-942-2857

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

Provider Enumeration Date	:	01/11/2006
Last Update Date	:	07/08/2007

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