Basic Information
| Provider Information | |||||||||
| NPI: | 1043400401 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | ASHIRA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 247 TAYLOR CT | ||||||||
| Address2: | |||||||||
| City: | BUFFALO GROVE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600894604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8473835315 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 7230 W NORTH AVE | ||||||||
| Address2: | SUITE 106B | ||||||||
| City: | ELMWOOD PARK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 607074261 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7084533000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2007 | ||||||||
| LastUpdateDate: | 11/23/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 036111927 | IL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | ME59614 | FL | N | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1619414 | 01 | BCBS GROUP | OTHER | 036111927 | 05 | IL | MEDICAID |