Healthcare Provider Details

I. General information

NPI: 1376820605
Provider Name (Legal Business Name): HENRY FORD HEALTH ST. JOHN HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2011
Last Update Date: 05/19/2026
Certification Date: 05/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21000 E 12 MILE RD STE 111
SAINT CLAIR SHORES MI
48081-1156
US

IV. Provider business mailing address

PO BOX 670884
DETROIT MI
48267-0884
US

V. Phone/Fax

Practice location:
  • Phone: 586-779-7610
  • Fax: 586-779-0031
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RA0201X
TaxonomyAllergy & Immunology (Internal Medicine) Physician
License Number
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code207YP0228X
TaxonomyPediatric Otolaryngology Physician
License Number
License Number StateMI
# 4
Primary TaxonomyN
Taxonomy Code207YS0123X
TaxonomyFacial Plastic Surgery Physician
License Number
License Number StateMI
# 5
Primary TaxonomyN
Taxonomy Code207YX0007X
TaxonomyPlastic Surgery within the Head & Neck (Otolaryngology) Physician
License Number
License Number StateMI
# 6
Primary TaxonomyN
Taxonomy Code207YX0901X
TaxonomyOtology & Neurotology Physician
License Number
License Number StateMI
# 7
Primary TaxonomyN
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License Number
License Number StateMI

VIII. Authorized Official

Name: KIMBERLY CEBALT
Title or Position: DIRECTOR
Credential:
Phone: 313-874-6764