MEDICARE: DR. ANDREW C 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	208000000X	Pediatrics Physician	125.059761	IL

General Provider Information

NPI Number	:	1639465131
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ANDREW C JOHNSON MD

Provider Business Mailing Address
First Line	:	2650 RIDGE AVE STE 1223
Second Line	:
City	:	EVANSTON
State	:	IL
Zip	:	60201-1700
Country	:	US
Telephone Number	:	847-570-2040
Fax Number	:

Provider Business Practice Location Address
First Line	:	49 S WAUKEGAN RD STE 100
Second Line	:
City	:	DEERFIELD
State	:	IL
Zip	:	60015-5204
Country	:	US
Telephone Number	:	847-945-4575
Fax Number	:

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

Provider Enumeration Date	:	06/22/2011
Last Update Date	:	03/11/2021

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