Provider Demographics
NPI:1265616528
Name:PHILLIP JOHNSON
Entity type:Organization
Organization Name:PHILLIP JOHNSON
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ORTHOTIST PROSTHETIST
Authorized Official - Prefix:MR
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:CPO
Authorized Official - Phone:540-951-2566
Mailing Address - Street 1:3635 S MAIN ST
Mailing Address - Street 2:STE A
Mailing Address - City:BLACKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24060-7021
Mailing Address - Country:US
Mailing Address - Phone:540-951-2566
Mailing Address - Fax:540-951-7818
Practice Address - Street 1:3635 S MAIN ST
Practice Address - Street 2:STE A
Practice Address - City:BLACKSBURG
Practice Address - State:VA
Practice Address - Zip Code:24060-7021
Practice Address - Country:US
Practice Address - Phone:540-951-2566
Practice Address - Fax:540-951-7818
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-21
Last Update Date:2008-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA5401900001Medicare NSC