Basic Information
| Provider Information | |||||||||
| NPI: | 1225255128 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | SAMUEL | ||||||||
| MiddleName: | ANDREW | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 55 WHITCHER STREET | ||||||||
| Address2: | SUITE 460 | ||||||||
| City: | MARIETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300601155 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7704277389 | ||||||||
| FaxNumber: | 7704271492 | ||||||||
| Practice Location | |||||||||
| Address1: | 55 WHITCHER ST NE | ||||||||
| Address2: | SUITE 460 | ||||||||
| City: | MARIETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300601155 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7704277389 | ||||||||
| FaxNumber: | 7704271492 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/20/2007 | ||||||||
| LastUpdateDate: | 08/01/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | 54909 | GA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | 003123548D | 05 | GA | MEDICAID | 003123548G | 05 | GA | MEDICAID | 003123548J | 05 | GA | MEDICAID | 003123548F | 05 | GA | MEDICAID | 003123548H | 05 | GA | MEDICAID | 003123548I | 05 | GA | MEDICAID | 003123548U | 05 | GA | MEDICAID | 003123548V | 05 | GA | MEDICAID | 54909 | 01 | GA | MD | OTHER | 003123548E | 05 | GA | MEDICAID | 003123548O | 05 | GA | MEDICAID | 003123548P | 05 | GA | MEDICAID | 003123548K | 05 | GA | MEDICAID | 003123548M | 05 | GA | MEDICAID | 003123548B | 05 | GA | MEDICAID | 003123548C | 05 | GA | MEDICAID | 003123548S | 05 | GA | MEDICAID | 003123548L | 05 | GA | MEDICAID | 003123548R | 05 | GA | MEDICAID | 003123548T | 05 | GA | MEDICAID | 29879 | 01 | SC | MEDICAL LICENSE | OTHER | 003123548N | 05 | GA | MEDICAID | 003123548Q | 05 | GA | MEDICAID |