Basic Information
| Provider Information | |||||||||
| NPI: | 1013412956 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | KEITH | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2001 VAIL AVE | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282071248 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043047000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 9855 HOSPITAL DR STE 102 | ||||||||
| Address2: | |||||||||
| City: | MAPLE GROVE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553694648 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7635815900 | ||||||||
| FaxNumber: | 7635815901 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2018 | ||||||||
| LastUpdateDate: | 07/29/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 238295 | NC | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 69882 | MN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.