Provider Demographics
NPI:1528056512
Name:JOHANSEN, ROBERT W (MD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:W
Last Name:JOHANSEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:717 STATE ST
Mailing Address - Street 2:SUITE 16, LL
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16501-1341
Mailing Address - Country:US
Mailing Address - Phone:814-877-7100
Mailing Address - Fax:814-877-2939
Practice Address - Street 1:201 STATE ST
Practice Address - Street 2:HAMOT FACULTY SPECIALISTS
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16550-0002
Practice Address - Country:US
Practice Address - Phone:814-877-4922
Practice Address - Fax:814-877-3622
Is Sole Proprietor?:No
Enumeration Date:2005-10-12
Last Update Date:2012-05-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAMD013856E2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0006028030005Medicaid
PA044058OtherBLUE SHIELD
PA110694OtherUNISON
PAP00170489OtherRR MEDICARE
PAP00170489OtherRR MEDICARE
PA0006028030005Medicaid