Provider Demographics
NPI:1609898600
Name:JOHNSON CLINIC PC
Entity type:Organization
Organization Name:JOHNSON CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:BONNIE
Authorized Official - Middle Name:E
Authorized Official - Last Name:MATTERN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-776-5235
Mailing Address - Street 1:800 3RD AVENUE SOUTHWEST
Mailing Address - Street 2:
Mailing Address - City:RUGBY
Mailing Address - State:ND
Mailing Address - Zip Code:58368
Mailing Address - Country:US
Mailing Address - Phone:701-776-5235
Mailing Address - Fax:701-776-5297
Practice Address - Street 1:800 3RD AVENUE SOUTHWEST
Practice Address - Street 2:
Practice Address - City:RUGBY
Practice Address - State:ND
Practice Address - Zip Code:58368
Practice Address - Country:US
Practice Address - Phone:701-776-5235
Practice Address - Fax:701-776-5297
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-25
Last Update Date:2007-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND10152Medicaid
ND353803Medicare Oscar/Certification
ND353838Medicare Oscar/Certification
ND353804Medicare Oscar/Certification
ND353813Medicare Oscar/Certification
ND0645970001Medicare NSC
ND10152Medicaid