Basic Information
| Provider Information | |||||||||
| NPI: | 1174595730 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | BRAD | ||||||||
| MiddleName: | NATHAN | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 405 W GREENLAWN AVE | ||||||||
| Address2: | #106 | ||||||||
| City: | LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 489102898 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5174822118 | ||||||||
| FaxNumber: | 5174826280 | ||||||||
| Practice Location | |||||||||
| Address1: | 405 W GREENLAWN AVE | ||||||||
| Address2: | #106 | ||||||||
| City: | LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 489102898 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5174822118 | ||||||||
| FaxNumber: | 5174826280 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/07/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | BS015087 | MI | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 4723010 | 05 | MI | MEDICAID |