Provider Demographics
NPI:1447473392
Name:CRAIG A. JOHNSON, M.D., PSC
Entity type:Organization
Organization Name:CRAIG A. JOHNSON, M.D., PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:OPAL
Authorized Official - Middle Name:R
Authorized Official - Last Name:BOONE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:270-259-9316
Mailing Address - Street 1:912 WALLACE AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:LEITCHFIELD
Mailing Address - State:KY
Mailing Address - Zip Code:42754-2404
Mailing Address - Country:US
Mailing Address - Phone:270-259-9316
Mailing Address - Fax:270-259-6571
Practice Address - Street 1:912 WALLACE AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:LEITCHFIELD
Practice Address - State:KY
Practice Address - Zip Code:42754-2404
Practice Address - Country:US
Practice Address - Phone:270-259-9316
Practice Address - Fax:270-259-6571
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY23893207VH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VH0002XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyHospice and Palliative MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
C76173Medicare UPIN
0991101Medicare ID - Type Unspecified