Provider Demographics
NPI:1447273933
Name:JOHNSON, KELLY E (MD)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:E
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3 W HAWTHORN PKWY
Mailing Address - Street 2:SUITE 150
Mailing Address - City:VERNON HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:60061-1446
Mailing Address - Country:US
Mailing Address - Phone:847-918-8282
Mailing Address - Fax:847-918-8215
Practice Address - Street 1:1701 E WOODFIELD ROAD
Practice Address - Street 2:SUITE 1000
Practice Address - City:SCHAUMBURG
Practice Address - State:IL
Practice Address - Zip Code:60173-5113
Practice Address - Country:US
Practice Address - Phone:847-240-2211
Practice Address - Fax:847-240-2418
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2013-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360827672084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036082767Medicaid
ILF31756Medicare UPIN
IL203608Medicare ID - Type Unspecified