Healthcare Provider Details

I. General information

NPI: 1417983990
Provider Name (Legal Business Name): ST. JOHN MACOMB-OAKLAND HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2006
Last Update Date: 01/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27379 DEQUINDRE RD
MADISON HEIGHTS MI
48071-3487
US

IV. Provider business mailing address

43750 GARFIELD RD SUITE 211
CLINTON TOWNSHIP MI
48038-1135
US

V. Phone/Fax

Practice location:
  • Phone: 248-398-4488
  • Fax: 248-398-4994
Mailing address:
  • Phone: 586-228-4652
  • Fax: 586-228-4533

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code261QM1200X
TaxonomyMagnetic Resonance Imaging (MRI) Clinic/Center
License Number
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number StateMI

VIII. Authorized Official

Name: MS. JENNIFER JOHNSON
Title or Position: DIRECTOR
Credential:
Phone: 877-996-9975