MEDICARE: TERRY L JOHANNESEN 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	207P00000X	Emergency Medicine Physician	15864	OK

General Provider Information

NPI Number	:	1881652428
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TERRY L JOHANNESEN MD

Provider Business Mailing Address
First Line	:	3450 SE FRANK PHILLIPS BLVD
Second Line	:
City	:	BARTLESVILLE
State	:	OK
Zip	:	74006
Country	:	US
Telephone Number	:	918-331-2444
Fax Number	:

Provider Business Practice Location Address
First Line	:	3500 SE FRANK PHILLIPS BLVD
Second Line	:
City	:	BARTLESVILLE
State	:	OK
Zip	:	74006-2300
Country	:	US
Telephone Number	:	918-331-1104
Fax Number	:	918-331-1446

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

Provider Enumeration Date	:	05/03/2006
Last Update Date	:	12/23/2015

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