MEDICARE: DR. JEREMY SCOTT 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	207V00000X	Obstetrics & Gynecology Physician	20869	OK
2	207V00000X	Obstetrics & Gynecology Physician	MD2007-0689	NM
3	207V00000X	Obstetrics & Gynecology Physician	036136882	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	:	1548249097
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JEREMY SCOTT JOHNSON M.D.

Provider Business Mailing Address
First Line	:	611 W. PARK ST.
Second Line	:	BWPC
City	:	URBANA
State	:	IL
Zip	:	61801-2500
Country	:	US
Telephone Number	:	217-383-6792
Fax Number	:	217-383-4966

Provider Business Practice Location Address
First Line	:	611 W. PARK ST.
Second Line	:	OB/GYN
City	:	URBANA
State	:	IL
Zip	:	61801-2500
Country	:	US
Telephone Number	:	217-383-3140
Fax Number	:	217-383-4966

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

Provider Enumeration Date	:	01/12/2006
Last Update Date	:	04/21/2015

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Directions to “ DR. JEREMY SCOTT JOHNSON M.D.” Practice Location

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