NPIMap

Individual provider Active NPI

Kimberly Sue Johnson, M.D.

  • Diagnostic Radiology Physician
  • 49684 Traverse City, Mi (Grand Traverse), MI
National Provider Identifier
1467682971
Registry record updated May 16, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Diagnostic Radiology PhysicianTaxonomy code 2085R0202X
License
4301094869 Issued in MI
Practice address
1105 Sixth Street
Suite#100
49684 Traverse City, Mi (Grand Traverse), MI 49684
Phone
(231) 935-5000
NPI assigned
Jul 17, 2009
Last updated
May 16, 2022By the provider in NPPES
Sex
Female
Sole proprietor
Yes

NPPES NPI Registry

Updated by the provider on May 16, 2022

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Diagnostic Radiology Physician 2085R0202X 4301094869 MI Primary

Addresses

Primary practice location

1105 Sixth Street
Suite#100
49684 Traverse City, Mi (Grand Traverse), MI 49684

Mailing address

PO Box 30516
Dept#9516
Lansing, MI 48909-7919
Phone (231) 935-0497

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MI
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20140528001305 MI Practitioner - Diagnostic Radiology 4082837604 Reassigns benefits to 5 organizations

Care Compare profile

Medicare Care Compare
Specialty
Diagnostic Radiology
Education
Michigan State University College of Human Medicine, 2009
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices
Grand Traverse Radiologists PCGroup PAC ID 6002866407, 32 clinicians

Practice addresses (Care Compare)

1105 6TH St
Traverse City, MI 49684-2345
Phone (231) 935-5000

Hospital & facility affiliations

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Doctor of Medicine

State licenses

LicenseStateTypeSpecialty
4301094869MIMDDiagnostic Radiology Physician

Practice roles

OrganizationSpecialtyStatusNew patients
Henry Ford Health System Current Accepting new patients
DLP Marquette Physician Practices Inc CurrentSince Aug 14, 2017 Accepting new patients
DLP Marquette Physician Practices Inc CurrentSince Aug 14, 2017 Accepting new patients
Henry Ford Health System Diagnostic Radiology CurrentSince Jul 1, 2014 Accepting new patients
Great Lakes Bay Health Centers CurrentSince Dec 15, 2019 Accepting new patients
Covenant Medical Center, Inc Diagnostic Radiology CurrentSince Jan 1, 2020 Accepting new patients
Grand Traverse Radiologists PC Diagnostic Radiology CurrentSince Jan 1, 2022 Accepting new patients
Great Lakes Bay Health Centers CurrentSince Dec 15, 2019 Accepting new patients
Henry Ford Health System CurrentSince Jul 1, 2014 Accepting new patients
Covenant Medical Center, Inc. Current Accepting new patients
Covenant Medical Center, Inc. Diagnostic Radiology CurrentSince Jan 1, 2020 Accepting new patients

Locations

2799 W Grand Blvd
Detroit, MI 48202
Phone (313) 876-2062

1414 W Fair Ave
Ste 36
Marquette, MI 49855
Phone (906) 225-3864

1447 N Harrison St
Saginaw, MI 48602
Phone (989) 583-4220

1522 Janes Ave
Saginaw, MI 48601
Phone (989) 755-0316

501 Lapeer Ave
#R
Saginaw, MI 48607
Phone (989) 753-6000

5570 State St
Saginaw, MI 48603
Phone (989) 583-0100

1105 Sixth St
Traverse City, MI 49684
Phone (231) 922-9000

1105 Sixth St
Ste 100
Traverse City, MI 49684

Organizations & group practices 11

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

Hospital & facility affiliations 6

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1247788800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1652659200000",
    "number": "1467682971",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 30516",
            "address_2": "DEPT#9516",
            "city": "LANSING",
            "state": "MI",
            "postal_code": "489097919",
            "telephone_number": "231-935-0497"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1105 SIXTH STREET",
            "address_2": "SUITE#100",
            "city": "49684 TRAVERSE CITY, MI (GRAND TRAVERSE)",
            "state": "MI",
            "postal_code": "49684",
            "telephone_number": "231-935-5000"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "JOHNSON",
        "first_name": "KIMBERLY",
        "middle_name": "SUE",
        "name_prefix": "Dr.",
        "credential": "M.D.",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2009-07-17",
        "last_updated": "2022-05-16",
        "certification_date": "2022-05-16",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "2085R0202X",
            "taxonomy_group": "",
            "desc": "Radiology, Diagnostic Radiology",
            "state": "MI",
            "license": "4301094869",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Sources for this page

Verify at the official NPI Registry.