Basic Information
| Provider Information | |||||||||
| NPI: | 1992887202 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MICHAEL W JOHNSON, MD, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 101 W MITCHELL ST | ||||||||
| Address2: | |||||||||
| City: | PETOSKEY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 497702323 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2314871000 | ||||||||
| FaxNumber: | 2314871002 | ||||||||
| Practice Location | |||||||||
| Address1: | 220 BURDETTE ST | ||||||||
| Address2: | |||||||||
| City: | SAINT IGNACE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 497811712 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9066430466 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | BAYS | ||||||||
| AuthorizedOfficialFirstName: | TINA | ||||||||
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| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2314871000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 4301054807 | MI | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 4301054807 | 01 | MI | STATE LICENSE | OTHER | 21407 | 01 | MI | MOLINA | OTHER | 0202410071 | 01 | MI | BCBSM PROVIDER ID# | OTHER |