MEDICARE: RONALD L JOHNSON

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	261QR1300X	Rural Health Clinic/Center	143946	IL

General Provider Information

NPI Number	:	1720088776
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RONALD L JOHNSON

Provider Business Mailing Address
First Line	:	1073 W WASHINGTON ST
Second Line	:
City	:	PITTSFIELD
State	:	IL
Zip	:	62363-1666
Country	:	US
Telephone Number	:	217-285-9661
Fax Number	:	217-285-4641

Provider Business Practice Location Address
First Line	:	1073 W WASHINGTON ST
Second Line	:
City	:	PITTSFIELD
State	:	IL
Zip	:	62363-1666
Country	:	US
Telephone Number	:	217-285-9661
Fax Number	:	217-285-4641

Authorized Official
Title or Position	:	OWNER/PHYSICIAN
Name	:	DR. RONALD L JOHNSON
Credential	:	MD
Telephone Number	:	217-285-9661

Provider Enumeration Date	:	07/29/2005
Last Update Date	:	08/22/2020

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