Basic Information
| Provider Information | |||||||||
| NPI: | 1588639520 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1700 S TAMIAMI TR | ||||||||
| Address2: | SARASOTA EMERGENCY ASSOCIATES PC | ||||||||
| City: | SARASOTA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 34239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9419178507 | ||||||||
| FaxNumber: | 9419178551 | ||||||||
| Practice Location | |||||||||
| Address1: | 1700 S TAMIAMI TRAIL | ||||||||
| Address2: | |||||||||
| City: | SARASOTA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 34239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9419178507 | ||||||||
| FaxNumber: | 9419178551 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/22/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | ME82651 | FL | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | P00271271 | 01 | RAILROAD MEDICARE | OTHER | 31019 | 01 | FL | BLUE CROSS BLUE SHIELD | OTHER |