Basic Information
| Provider Information | |||||||||
| NPI: | 1922058361 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | KIM | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | THORNTON | ||||||||
| OtherFirstName: | KIM | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | D.O. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3409 LUDINGTON ST | ||||||||
| Address2: | SUITE 204 | ||||||||
| City: | ESCANABA | ||||||||
| State: | MI | ||||||||
| PostalCode: | 498294212 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9067861356 | ||||||||
| FaxNumber: | 9067894503 | ||||||||
| Practice Location | |||||||||
| Address1: | 3409 LUDINGTON ST | ||||||||
| Address2: | SUITE 204 | ||||||||
| City: | ESCANABA | ||||||||
| State: | MI | ||||||||
| PostalCode: | 498294212 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9067861356 | ||||||||
| FaxNumber: | 9067894503 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2006 | ||||||||
| LastUpdateDate: | 03/31/2010 | ||||||||
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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 | 207V00000X | 5101013033 | MI | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 1922058361 | 05 | MI | MEDICAID | 5211399 | 01 | BCBS | OTHER |