Provider Demographics
NPI:1962500900
Name:JOHNSON, SCOTT HAZLEHURST (MD)
Entity type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:HAZLEHURST
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16001 W 9 MILE RD # 3
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-4818
Mailing Address - Country:US
Mailing Address - Phone:248-849-2600
Mailing Address - Fax:248-849-2610
Practice Address - Street 1:1 GENESYS PKWY STE 3452
Practice Address - Street 2:
Practice Address - City:GRAND BLANC
Practice Address - State:MI
Practice Address - Zip Code:48439-8065
Practice Address - Country:US
Practice Address - Phone:248-849-2600
Practice Address - Fax:248-849-2610
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2021-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC36390208G00000X
MI4301087166208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3303312811OtherBCBS INDIVIDUAL PIN
SCPENDINGMedicaid
MI4855726Medicaid
MI4855726Medicaid
MI3303312811OtherBCBS INDIVIDUAL PIN
SCPENDINGMedicare PIN