MEDICARE: CHARLES BRADFORD JOHNSTON 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	036078749	IL
2	208000000X	Pediatrics Physician	036078749	IL

General Provider Information

NPI Number	:	1831288422
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHARLES BRADFORD JOHNSTON MD

Provider Business Mailing Address
First Line	:	1102 CHICAGO AVE
Second Line	:
City	:	OAK PARK
State	:	IL
Zip	:	60302-1804
Country	:	US
Telephone Number	:	708-948-7772
Fax Number	:	708-948-7773

Provider Business Practice Location Address
First Line	:	1102 CHICAGO AVE
Second Line	:
City	:	OAK PARK
State	:	IL
Zip	:	60302-1804
Country	:	US
Telephone Number	:	708-948-7772
Fax Number	:	708-948-7773

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

Provider Enumeration Date	:	10/12/2006
Last Update Date	:	12/13/2010

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