Basic Information
| Provider Information | |||||||||
| NPI: | 1588745574 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | RONALD | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2311 CRESCENT HILL DR | ||||||||
| Address2: | |||||||||
| City: | OWENSBORO | ||||||||
| State: | KY | ||||||||
| PostalCode: | 423032032 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2706845005 | ||||||||
| FaxNumber: | 2709264432 | ||||||||
| Practice Location | |||||||||
| Address1: | 815 E PARRISH AVE | ||||||||
| Address2: | SUITE 460 | ||||||||
| City: | OWENSBORO | ||||||||
| State: | KY | ||||||||
| PostalCode: | 423033222 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2706845005 | ||||||||
| FaxNumber: | 2709264432 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2006 | ||||||||
| 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 | 207L00000X | 16792 | KY | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 64167927 | 05 | KY | MEDICAID |