Basic Information
| Provider Information | |||||||||
| NPI: | 1457644254 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | MEGAN | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1497 W ELK AVE | ||||||||
| Address2: | SUITE 21 | ||||||||
| City: | ELIZABETHTON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376432895 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4235427420 | ||||||||
| FaxNumber: | 4235427425 | ||||||||
| Practice Location | |||||||||
| Address1: | 1497 W ELK AVE | ||||||||
| Address2: | SUITE 21 | ||||||||
| City: | ELIZABETHTON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376432895 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4235427420 | ||||||||
| FaxNumber: | 4235427425 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/26/2011 | ||||||||
| LastUpdateDate: | 02/10/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 51290 | TN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1457644254 | 05 | VA | MEDICAID | 6023539 | 01 | TN | BLUECARE | OTHER | Q008037 | 05 | TN | MEDICAID |