Healthcare Provider Details

I. General information

NPI: 1598713414
Provider Name (Legal Business Name): ST JOHN HOSPITAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2006
Last Update Date: 10/12/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22101 MOROSS RD
DETROIT MI
48236-2148
US

IV. Provider business mailing address

43800 GARFIELD RD SUITE 201
CLINTON TWP MI
48038-1136
US

V. Phone/Fax

Practice location:
  • Phone: 586-228-4635
  • Fax: 586-228-4520
Mailing address:
  • Phone: 586-228-4635
  • Fax: 586-228-4520

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0120X
TaxonomyPediatric Surgery Physician
License Number
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number StateMI

VIII. Authorized Official

Name: SANDRA ELLEN WHITMAN
Title or Position: DIRECTOR, PHYSICIAN BILLING SERVICE
Credential:
Phone: 248-746-5822