MEDICARE: DR. SHELLY 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	207R00000X	Internal Medicine Physician	MD08863	RI

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	007056629	OTHER	RI	MEDICARE

Other Identifiers

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

General Provider Information

NPI Number	:	1528055191
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SHELLY JOHNSON MD

Provider Business Mailing Address
First Line	:	10 DAVOL SQ
Second Line	:	SUITE 400
City	:	PROVIDENCE
State	:	RI
Zip	:	02903-4754
Country	:	US
Telephone Number	:	401-421-4000
Fax Number	:	401-272-1456

Provider Business Practice Location Address
First Line	:	59 S COUNTY COMMONS WAY FL H32
Second Line	:
City	:	SOUTH KINGSTOWN
State	:	RI
Zip	:	02879-8270
Country	:	US
Telephone Number	:	401-783-0084
Fax Number	:	401-782-0005

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

Provider Enumeration Date	:	09/29/2005
Last Update Date	:	04/02/2024

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