Healthcare Provider Details

I. General information

NPI: 1679881510
Provider Name (Legal Business Name): ST. JOHN HOSPITAL AND MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2010
Last Update Date: 09/14/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19901 E 10 MILE RD
SAINT CLAIR SHORES MI
48080-1069
US

IV. Provider business mailing address

19901 E 10 MILE RD
SAINT CLAIR SHORES MI
48080-1069
US

V. Phone/Fax

Practice location:
  • Phone: 586-777-1277
  • Fax: 586-777-0106
Mailing address:
  • Phone: 586-777-1277
  • Fax: 586-777-0106

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateMI

VIII. Authorized Official

Name: JENNIFER JOHNSON
Title or Position: DIRECTOR
Credential:
Phone: 586-228-4560