Basic Information
| Provider Information | |||||||||
| NPI: | 1457386716 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | NEAL | ||||||||
| MiddleName: | LORN | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PHYSICAL THERAPIST | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 22487 | ||||||||
| Address2: | |||||||||
| City: | GREEN BAY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 543052487 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9204457226 | ||||||||
| FaxNumber: | 9204457229 | ||||||||
| Practice Location | |||||||||
| Address1: | 440 WOODWARD AVE | ||||||||
| Address2: | |||||||||
| City: | IRON MOUNTAIN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 498014631 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9067743779 | ||||||||
| FaxNumber: | 9067746712 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2006 | ||||||||
| LastUpdateDate: | 12/09/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | 4326 024 | WI | N | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | 225100000X | 5501003258 | MI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 650012048 | 01 | MI | RAILROAD MEDICARE | OTHER | 1009687 | 01 | PREFERRED ONE | OTHER |