Provider Demographics
NPI:1740445337
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:PO BOX 67000
Mailing Address - Street 2:DEPARTMENT 184101
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48267-0002
Mailing Address - Country:US
Mailing Address - Phone:877-996-9975
Mailing Address - Fax:586-228-4533
Practice Address - Street 1:46591 ROMEO PLANK RD
Practice Address - Street 2:SUITE 137
Practice Address - City:MACOMB
Practice Address - State:MI
Practice Address - Zip Code:48044-5742
Practice Address - Country:US
Practice Address - Phone:586-226-6226
Practice Address - Fax:586-226-6255
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-23
Last Update Date:2011-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2085D0003X, 2085N0700X, 2085N0904X, 2085P0229X, 2085R0204X, 2085U0001X, 247100000X, 2471B0102X, 2471C3402X, 2471M2300X, 2471N0900X, 2471S1302X, 2471V0105X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
No2085D0003XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic NeuroimagingGroup - Multi-Specialty
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiologyGroup - Multi-Specialty
No2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear RadiologyGroup - Multi-Specialty
No2085P0229XAllopathic & Osteopathic PhysiciansRadiologyPediatric RadiologyGroup - Multi-Specialty
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Multi-Specialty
No2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic UltrasoundGroup - Multi-Specialty
No247100000XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistGroup - Multi-Specialty
No2471B0102XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistBone DensitometryGroup - Multi-Specialty
No2471C3402XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistRadiographyGroup - Multi-Specialty
No2471M2300XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistMammographyGroup - Multi-Specialty
No2471N0900XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistNuclear Medicine TechnologyGroup - Multi-Specialty
No2471S1302XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistSonographyGroup - Multi-Specialty
No2471V0105XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistVascular SonographyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI310E022080OtherBCBSM GROUP NUMBER
MI0N40170Medicare PIN