Basic Information
| Provider Information | |||||||||
| NPI: | 1699718023 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | ERIC | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 915 HIGHLAND BLVD | ||||||||
| Address2: | |||||||||
| City: | BOZEMAN | ||||||||
| State: | MT | ||||||||
| PostalCode: | 597156902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4064145000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 935 HIGHLAND BLVD STE 2180 | ||||||||
| Address2: | |||||||||
| City: | BOZEMAN | ||||||||
| State: | MT | ||||||||
| PostalCode: | 597156904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4064145512 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2006 | ||||||||
| LastUpdateDate: | 03/11/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | M4932 | ID | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207PE0005X | M-4932 | ID | N | Allopathic & Osteopathic Physicians | Emergency Medicine | Undersea and Hyperbaric Medicine | 207Q00000X | M-4932 | ID | N | Allopathic & Osteopathic Physicians | Family Medicine | 207PE0005X | 34447 | MT | Y | Allopathic & Osteopathic Physicians | Emergency Medicine | Undersea and Hyperbaric Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1699718023 | 05 | MT | MEDICAID |