Basic Information
| Provider Information | |||||||||
| NPI: | 1255331229 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | RONALD | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1025 MAINE ST | ||||||||
| Address2: | |||||||||
| City: | QUINCY | ||||||||
| State: | IL | ||||||||
| PostalCode: | 623014038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2172226550 | ||||||||
| FaxNumber: | 2172772253 | ||||||||
| Practice Location | |||||||||
| Address1: | 320 N MADISON | ||||||||
| Address2: | |||||||||
| City: | PITTSFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 62363 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2172859601 | ||||||||
| FaxNumber: | 2172856188 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/29/2005 | ||||||||
| LastUpdateDate: | 08/12/2013 | ||||||||
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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 | 207Q00000X | 036056997 | IL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0360569971 | 05 | IL | MEDICAID |