Provider Demographics
NPI:1962623280
Name:JOHNSON MEDICAL CLINIC
Entity type:Organization
Organization Name:JOHNSON MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER AND SOLE PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:CARLA
Authorized Official - Middle Name:A
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:920-487-5635
Mailing Address - Street 1:N8434 COUNTY RD S
Mailing Address - Street 2:
Mailing Address - City:ALGOMA
Mailing Address - State:WI
Mailing Address - Zip Code:54201-9515
Mailing Address - Country:US
Mailing Address - Phone:920-487-5635
Mailing Address - Fax:
Practice Address - Street 1:N8434 COUNTY RD S
Practice Address - Street 2:
Practice Address - City:ALGOMA
Practice Address - State:WI
Practice Address - Zip Code:54201-9515
Practice Address - Country:US
Practice Address - Phone:920-487-5635
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-02
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIHO35675OtherWISCONSIN CORPORATE NUMBE
WI30094500Medicaid
WIBH5013177OtherDEA LICENSE
WIHO35675OtherWISCONSIN CORPORATE NUMBE
WI000033003Medicare PIN
WIBH5013177OtherDEA LICENSE