Basic Information
Provider Information | |||||||||
NPI: | 1801896022 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | JOHNSON | ||||||||
FirstName: | MARY | ||||||||
MiddleName: | H | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 16000 JOHNSTON MEMORIAL DR | ||||||||
Address2: | 4TH FLOOR | ||||||||
City: | ABINGDON | ||||||||
State: | VA | ||||||||
PostalCode: | 242117664 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2762584050 | ||||||||
FaxNumber: | 2762584056 | ||||||||
Practice Location | |||||||||
Address1: | 16000 JOHNSTON MEMORIAL DR | ||||||||
Address2: | 4TH FLOOR | ||||||||
City: | ABINGDON | ||||||||
State: | VA | ||||||||
PostalCode: | 242117664 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2762584050 | ||||||||
FaxNumber: | 2762584056 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/29/2005 | ||||||||
LastUpdateDate: | 02/10/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207PP0204X | 27331 | TN | N |   | Allopathic & Osteopathic Physicians | Emergency Medicine | Pediatric Emergency Medicine | 207PP0204X | 9401227 | NC | N |   | Allopathic & Osteopathic Physicians | Emergency Medicine | Pediatric Emergency Medicine | 208000000X | 0101052591 | VA | Y |   | Allopathic & Osteopathic Physicians | Pediatrics |   |
ID Information
ID | Type | State | Issuer | Description | 1801896022 | 05 | VA |   | MEDICAID | 46440 | 01 | NC | BCBS | OTHER | Q015237 | 05 | TN |   | MEDICAID | 8946440 | 05 | NC |   | MEDICAID | NPI | 01 | NC | MEDCOST | OTHER |