Basic Information
| Provider Information | |||||||||
| NPI: | 1609898600 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | JOHNSON CLINIC PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 800 3RD AVENUE SOUTHWEST | ||||||||
| Address2: | |||||||||
| City: | RUGBY | ||||||||
| State: | ND | ||||||||
| PostalCode: | 58368 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7017765235 | ||||||||
| FaxNumber: | 7017765297 | ||||||||
| Practice Location | |||||||||
| Address1: | 800 3RD AVENUE SOUTHWEST | ||||||||
| Address2: | |||||||||
| City: | RUGBY | ||||||||
| State: | ND | ||||||||
| PostalCode: | 58368 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7017765235 | ||||||||
| FaxNumber: | 7017765297 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2006 | ||||||||
| LastUpdateDate: | 11/23/2007 | ||||||||
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| AuthorizedOfficialLastName: | MATTERN | ||||||||
| AuthorizedOfficialFirstName: | BONNIE | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 7017765235 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 10152 | 05 | ND | MEDICAID |