Basic Information
Provider Information | |||||||||
NPI: | 1750606075 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | JOHNSON | ||||||||
FirstName: | SUSANNAH | ||||||||
MiddleName: | E | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 68 | ||||||||
Address2: |   | ||||||||
City: | POLLOCKSVILLE | ||||||||
State: | NC | ||||||||
PostalCode: | 285730068 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2526384023 | ||||||||
FaxNumber: | 2526332833 | ||||||||
Practice Location | |||||||||
Address1: | 2604 DR MARTIN LUTHER KING JR BLVD | ||||||||
Address2: |   | ||||||||
City: | NEW BERN | ||||||||
State: | NC | ||||||||
PostalCode: | 285624238 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2526384023 | ||||||||
FaxNumber: | 2526332833 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/30/2010 | ||||||||
LastUpdateDate: | 07/13/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/13/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 50503 | TN | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 208M00000X | 50503 | TN | N |   | Allopathic & Osteopathic Physicians | Hospitalist |   | 207R00000X | 2021-01038 | NC | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 7100265170 | 05 | KY |   | MEDICAID | Q001805 | 05 | TN |   | MEDICAID | 6002116 | 01 | TN | BLUECROSS BLUESHIELD | OTHER | 6010882 | 01 | TN | BLUE CROSS-BLUE SHIELD | OTHER |