Basic Information
| Provider Information | |||||||||
| NPI: | 1952371874 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 822 | ||||||||
| Address2: | |||||||||
| City: | CULLMAN | ||||||||
| State: | AL | ||||||||
| PostalCode: | 350560822 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2567349472 | ||||||||
| FaxNumber: | 2567349272 | ||||||||
| Practice Location | |||||||||
| Address1: | 1403 WALL STREET | ||||||||
| Address2: | |||||||||
| City: | CULLMAN | ||||||||
| State: | AL | ||||||||
| PostalCode: | 350550000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2567349472 | ||||||||
| FaxNumber: | 2567349272 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/24/2006 | ||||||||
| LastUpdateDate: | 09/13/2013 | ||||||||
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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 | 207L00000X | 00015459 | AL | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 000086453 | 05 | AL | MEDICAID |