Healthcare Provider Details

I. General information

NPI: 1811068760
Provider Name (Legal Business Name): ST JOHN HOSPITAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/13/2006
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 STE 200
CLINTON TOWNSHIP 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 TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number State

VIII. Authorized Official

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