Basic Information
| Provider Information | |||||||||
| NPI: | 1912320169 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | JOHNSTON PRIMARY CARE PHYSICIAN SERVICES, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | JOHNSTON MEDICAL ASSOCIATES - INTERNAL MEDICINE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 514 N BRIGHTLEAF BLVD | ||||||||
| Address2: | SUITE 1620 | ||||||||
| City: | SMITHFIELD | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275774407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9199387182 | ||||||||
| FaxNumber: | 9199387185 | ||||||||
| Practice Location | |||||||||
| Address1: | 514 N BRIGHTLEAF BLVD | ||||||||
| Address2: | SUITE 1620 | ||||||||
| City: | SMITHFIELD | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275774407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9199387182 | ||||||||
| FaxNumber: | 9199387185 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/23/2014 | ||||||||
| LastUpdateDate: | 01/23/2014 | ||||||||
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| AuthorizedOfficialLastName: | WOODRUFF | ||||||||
| AuthorizedOfficialFirstName: | TRACEY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9199387374 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.