Provider Demographics
NPI:1366573099
Name:ST JOHN HOSPITAL AND MEDICAL CENTER
Entity type:Organization
Organization Name:ST JOHN HOSPITAL AND MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:V.P. - FINANCE
Authorized Official - Prefix:MR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:J
Authorized Official - Last Name:PALAZZOLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-343-3558
Mailing Address - Street 1:28000 DEQUINDRE RD
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48092-2468
Mailing Address - Country:US
Mailing Address - Phone:586-753-0011
Mailing Address - Fax:
Practice Address - Street 1:22201 MOROSS RD
Practice Address - Street 2:SUITE 70
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48236-2169
Practice Address - Country:US
Practice Address - Phone:586-753-0011
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-07
Last Update Date:2009-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No207U00000XAllopathic & Osteopathic PhysiciansNuclear MedicineGroup - Multi-Specialty
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0Q26016OtherBCBSM PIN
MI0Q26016OtherBCBSM PIN