Provider Demographics
NPI:1063422681
Name:JOHNSON, BETH M (DC)
Entity type:Individual
Prefix:
First Name:BETH
Middle Name:M
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:BETH
Other - Middle Name:M
Other - Last Name:ORENDORFF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DC
Mailing Address - Street 1:419 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:IL
Mailing Address - Zip Code:62656-2019
Mailing Address - Country:US
Mailing Address - Phone:217-735-2527
Mailing Address - Fax:
Practice Address - Street 1:419 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:IL
Practice Address - Zip Code:62656-2019
Practice Address - Country:US
Practice Address - Phone:217-735-2527
Practice Address - Fax:217-732-4377
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2019-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038-009168111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL038-009168Medicaid
ILCK6783OtherRAILROAD MEDICARE GROUP
IL350056549OtherRAILROAD MEDICARE
IL209275Medicare Oscar/Certification