MEDICARE: ST. JOHN HOSPITAL AND MEDICAL CENTER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician		MI
2	207Q00000X	Family Medicine Physician		MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	080E017710	OTHER	MI	BCBS GROUP NUMBER

General Provider Information

NPI Number	:	1679881510
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ST. JOHN HOSPITAL AND MEDICAL CENTER

Provider Business Mailing Address
First Line	:	19901 E 10 MILE RD
Second Line	:
City	:	SAINT CLAIR SHORES
State	:	MI
Zip	:	48080-1069
Country	:	US
Telephone Number	:	586-777-1277
Fax Number	:	586-777-0106

Provider Business Practice Location Address
First Line	:	19901 E 10 MILE RD
Second Line	:
City	:	SAINT CLAIR SHORES
State	:	MI
Zip	:	48080-1069
Country	:	US
Telephone Number	:	586-777-1277
Fax Number	:	586-777-0106

Authorized Official
Title or Position	:	DIRECTOR
Name	:	JENNIFER JOHNSON
Credential	:
Telephone Number	:	586-228-4560

Provider Enumeration Date	:	09/14/2010
Last Update Date	:	09/14/2010

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Directions to “ST. JOHN HOSPITAL AND MEDICAL CENTER ” Practice Location

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