Provider Demographics
NPI:1306882485
Name:JOHNSON, RAYMOND JOHN (PT MPT)
Entity type:Individual
Prefix:MR
First Name:RAYMOND
Middle Name:JOHN
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PT MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:226 GOODFORD RD
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19154-4322
Mailing Address - Country:US
Mailing Address - Phone:215-612-7992
Mailing Address - Fax:
Practice Address - Street 1:1345 EASTON RD
Practice Address - Street 2:
Practice Address - City:ROSLYN
Practice Address - State:PA
Practice Address - Zip Code:19001-2401
Practice Address - Country:US
Practice Address - Phone:215-885-2022
Practice Address - Fax:215-885-7408
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT008454L225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA01618325Medicaid
PA0804821000OtherINDEPENDENCE BLUE CROSS
PA30009513OtherKEYSTONE MERCY
PA5235466OtherAETNA HEALTH PLAN