Basic Information
| Provider Information | |||||||||
| NPI: | 1609920032 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | EDWARD | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1085 S LINDEN RD | ||||||||
| Address2: | SUITE 150 | ||||||||
| City: | FLINT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 485323421 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8107323240 | ||||||||
| FaxNumber: | 8102300280 | ||||||||
| Practice Location | |||||||||
| Address1: | ONE HURLEY PLAZA | ||||||||
| Address2: | FAMILY AMBULATORY CLINIC | ||||||||
| City: | FLINT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8102579191 | ||||||||
| FaxNumber: | 8102579187 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/23/2007 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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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 | 207R00000X | 4301050587 | MI | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 4113290 | 05 | MI | MEDICAID | OB56031 | 01 | MI | BLUE CROSS BLUE SHIELD MI | OTHER |