Basic Information
| Provider Information | |||||||||
| NPI: | 1396789384 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | JAY | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 162972 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303212972 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8004433672 | ||||||||
| FaxNumber: | 8655607310 | ||||||||
| Practice Location | |||||||||
| Address1: | 501 REDMOND RD NW | ||||||||
| Address2: | |||||||||
| City: | ROME | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301651415 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7062910291 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2006 | ||||||||
| LastUpdateDate: | 06/23/2008 | ||||||||
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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 | 207P00000X | 030326 | GA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0003399385F | 05 | GA | MEDICAID | 930060783 | 01 | GA | RRGA | OTHER |