Provider Demographics
NPI:1972536340
Name:JOHN M. STAFFORD, MD, AND ASSOCIATES, P.C.
Entity type:Organization
Organization Name:JOHN M. STAFFORD, MD, AND ASSOCIATES, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:STAFFORD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:269-428-2552
Mailing Address - Street 1:3800 HOLLYWOOD RD STE 101
Mailing Address - Street 2:ROYALTON MED CENTER
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085-8511
Mailing Address - Country:US
Mailing Address - Phone:269-428-2552
Mailing Address - Fax:269-428-2943
Practice Address - Street 1:3800 HOLLYWOOD RD STE 101
Practice Address - Street 2:ROYALTON MED CENTER
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085-8511
Practice Address - Country:US
Practice Address - Phone:269-428-2552
Practice Address - Fax:269-428-2943
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-09
Last Update Date:2009-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301044515207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI310272010Medicaid
MI0M00730Medicare ID - Type Unspecified
MIB43647Medicare UPIN