Healthcare Provider Details

I. General information

NPI: 1740382183
Provider Name (Legal Business Name): SJMH MEDICAL PRACTICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/05/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44555 WOODWARD AVE SUITE 105
PONTIAC MI
48341-5031
US

IV. Provider business mailing address

44428 WOODWARD AVE LOWER LEVEL
PONTIAC MI
48341-5009
US

V. Phone/Fax

Practice location:
  • Phone: 248-858-6773
  • Fax: 248-858-3921
Mailing address:
  • Phone: 248-858-6144
  • Fax: 248-858-6232

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0004X
TaxonomyOrthopaedic Foot and Ankle Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: JACK WEINER
Title or Position: CEO
Credential:
Phone: 248-858-3140