Basic Information
Provider Information | |||||||||
NPI: | 1518929538 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | JOHNSON | ||||||||
FirstName: | KENNETH | ||||||||
MiddleName: | H | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | DO | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2 HEALTH CENTER DR | ||||||||
Address2: |   | ||||||||
City: | ATHENS | ||||||||
State: | OH | ||||||||
PostalCode: | 457012907 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7405931660 | ||||||||
FaxNumber: | 7405930179 | ||||||||
Practice Location | |||||||||
Address1: | 2 HEALTH CENTER DR | ||||||||
Address2: |   | ||||||||
City: | ATHENS | ||||||||
State: | OH | ||||||||
PostalCode: | 457012907 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7405931660 | ||||||||
FaxNumber: | 7405930179 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/05/2006 | ||||||||
LastUpdateDate: | 07/20/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 204D00000X | 1437 | ME | Y |   | Allopathic & Osteopathic Physicians | Neuromusculoskeletal Medicine & OMM |   | 207Q00000X | 1437 | ME | N |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 212530099 | 05 | ME |   | MEDICAID | 010211810001 | 01 | ME | TRICARE | OTHER |