Provider Demographics
NPI:1386892834
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:586-228-4560
Mailing Address - Street 1:21099 MASONIC BLVD
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48082-1045
Mailing Address - Country:US
Mailing Address - Phone:586-296-6213
Mailing Address - Fax:586-296-8180
Practice Address - Street 1:21099 MASONIC BLVD
Practice Address - Street 2:
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48082-1045
Practice Address - Country:US
Practice Address - Phone:586-296-6213
Practice Address - Fax:586-296-8180
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-08
Last Update Date:2012-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI207Q00000X, 261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI700E034110OtherBCBS GROUP NUMBER
MI700E014700OtherBCBS GROUP NUMBER
MI700E031610OtherBCBS GROUP NUMBER
MI700E031610OtherBCBS GROUP NUMBER