Basic Information
| Provider Information | |||||||||
| NPI: | 1710190947 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 24701 EUCLID AVENUE | ||||||||
| Address2: | 3RD FLOOR | ||||||||
| City: | EUCLID | ||||||||
| State: | OH | ||||||||
| PostalCode: | 44117 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 11100 EUCLID AVENUE | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 44106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2168447700 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/07/2007 | ||||||||
| LastUpdateDate: | 03/14/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP3000X | 35-086941 | OH | N | Allopathic & Osteopathic Physicians | Anesthesiology | Pediatric Anesthesiology | 2080P0203X | 35086941 | OH | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Critical Care Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1026733980001 | 05 | PA | MEDICAID | 2957870 | 05 | OH | MEDICAID |