MEDICARE: MRS. BERNICE IK-JANG MI JOHNSON PHYISICAN ASSISTANT

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	363AM0700X	Medical Physician Assistant	085-001948	IL

General Provider Information

NPI Number	:	1831110279
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. BERNICE IK-JANG MI JOHNSON PHYISICAN ASSISTANT

Provider Business Mailing Address
First Line	:	7300 W COLLEGE DR
Second Line	:	1NW
City	:	PALOS HEIGHTS
State	:	IL
Zip	:	60463-1152
Country	:	US
Telephone Number	:	708-671-1374
Fax Number	:	708-671-1378

Provider Business Practice Location Address
First Line	:	7300 W COLLEGE DR
Second Line	:	1NW
City	:	PALOS HEIGHTS
State	:	IL
Zip	:	60463-1152
Country	:	US
Telephone Number	:	708-671-1374
Fax Number	:	708-671-1378

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

Provider Enumeration Date	:	07/21/2006
Last Update Date	:	02/19/2013

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