MEDICARE: EBONY NICOLE JOHNSON MD

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	207Q00000X	Family Medicine Physician	03612077	IL

General Provider Information

NPI Number	:	1497847255
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EBONY NICOLE JOHNSON MD

Provider Business Mailing Address
First Line	:	27702 NETWORK PL
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60673-1277
Country	:	US
Telephone Number	:	708-862-7674
Fax Number	:	708-862-1781

Provider Business Practice Location Address
First Line	:	4742 CAL SAG RD
Second Line	:
City	:	CRESTWOOD
State	:	IL
Zip	:	60418
Country	:	US
Telephone Number	:	708-915-2727
Fax Number	:

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

Provider Enumeration Date	:	09/29/2006
Last Update Date	:	07/23/2018

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