Basic Information
| Provider Information | |||||||||
| NPI: | 1831580604 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JOHNNA L KOHL MD LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4001 DALE ST STE 201 | ||||||||
| Address2: | |||||||||
| City: | ANCHORAGE | ||||||||
| State: | AK | ||||||||
| PostalCode: | 995085445 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9075693600 | ||||||||
| FaxNumber: | 9075693200 | ||||||||
| Practice Location | |||||||||
| Address1: | 4001 DALE ST STE 201 | ||||||||
| Address2: | |||||||||
| City: | ANCHORAGE | ||||||||
| State: | AK | ||||||||
| PostalCode: | 995085445 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9075693600 | ||||||||
| FaxNumber: | 9075693200 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/13/2015 | ||||||||
| LastUpdateDate: | 05/26/2015 | ||||||||
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| AuthorizedOfficialLastName: | KOHL | ||||||||
| AuthorizedOfficialFirstName: | JOHNNA | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9075693600 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | 4771 | AK | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 1014305 | 05 | AK | MEDICAID |