Basic Information
| Provider Information | |||||||||
| NPI: | 1669481057 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | RORY | ||||||||
| MiddleName: | MICHAEL | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 610 W . ADAMS STREET | ||||||||
| Address2: | |||||||||
| City: | BLACK RIVER FALLS | ||||||||
| State: | WI | ||||||||
| PostalCode: | 546159010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7152844311 | ||||||||
| FaxNumber: | 7152842568 | ||||||||
| Practice Location | |||||||||
| Address1: | 610 W. ADAMS STREET | ||||||||
| Address2: | |||||||||
| City: | BLACK RIVER FALLS | ||||||||
| State: | WI | ||||||||
| PostalCode: | 546159010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7152844311 | ||||||||
| FaxNumber: | 7152842568 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2006 | ||||||||
| LastUpdateDate: | 02/29/2012 | ||||||||
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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 | 207Q00000X | 41453 | WI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 33328200 | 05 | WI | MEDICAID |