Healthcare Provider Details

I. General information

NPI: 1164655585
Provider Name (Legal Business Name): ST JOHN HOSPITAL AND MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/02/2009
Last Update Date: 09/02/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19229 MACK AVE 24
GROSSE POINTE WOODS MI
48236-2858
US

IV. Provider business mailing address

19229 MACK AVE 24
GROSSE POINTE WOODS MI
48236-2858
US

V. Phone/Fax

Practice location:
  • Phone: 313-884-5522
  • Fax: 313-884-6054
Mailing address:
  • Phone: 313-884-5522
  • Fax: 313-884-6054

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number
License Number State

VIII. Authorized Official

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