Basic Information
| Provider Information | |||||||||
| NPI: | 1366762213 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | N | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3621 S STATE ST | ||||||||
| Address2: | |||||||||
| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481081633 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7346475299 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1675 DEMPSTER ST FL 3 | ||||||||
| Address2: | |||||||||
| City: | PARK RIDGE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600681110 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8473189330 | ||||||||
| FaxNumber: | 8477239441 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2010 | ||||||||
| LastUpdateDate: | 07/27/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 4301107206 | MI | N | Allopathic & Osteopathic Physicians | Surgery | 2086S0102X | 4301107206 | MI | N | Allopathic & Osteopathic Physicians | Surgery | Surgical Critical Care | 2086S0120X | 4301107206 | MI | Y | Allopathic & Osteopathic Physicians | Surgery | Pediatric Surgery |
No ID Information.