Provider Demographics
NPI:1386716520
Name:ST. JOHN HOSPITAL AND MEDICAL CENTER
Entity type:Organization
Organization Name:ST. JOHN HOSPITAL AND MEDICAL CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:877-996-9975
Mailing Address - Street 1:19901 E 10 MILE RD
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48080-1069
Mailing Address - Country:US
Mailing Address - Phone:586-777-1277
Mailing Address - Fax:586-777-0106
Practice Address - Street 1:19901 E 10 MILE RD
Practice Address - Street 2:
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48080-1069
Practice Address - Country:US
Practice Address - Phone:586-777-1277
Practice Address - Fax:586-777-0106
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-14
Last Update Date:2011-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MICG4134OtherRAILROAD MEDICARE GROUP NUMBER
MI0P27380OtherMEDICARE GROUP LEGACY #
MI080E017710OtherBCBSM GROUP NUMBER
MICG3113OtherRAILROAD MEDICARE GROUP NUMBER
MI0P27380Medicare PIN