Healthcare Provider Details

I. General information

NPI: 1285902627
Provider Name (Legal Business Name): ST. JOHN HOSPITAL AND MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2011
Last Update Date: 12/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21000 E 12 MILE RD SUITE 111
SAINT CLAIR SHORES MI
48081-1116
US

IV. Provider business mailing address

21000 E 12 MILE RD SUITE 111
SAINT CLAIR SHORES MI
48081-1116
US

V. Phone/Fax

Practice location:
  • Phone: 586-779-7610
  • Fax: 586-779-1391
Mailing address:
  • Phone: 586-779-7610
  • Fax: 586-779-1391

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code231HA2400X
TaxonomyAssistive Technology Practitioner Audiologist
License Number
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code231HA2500X
TaxonomyAssistive Technology Supplier Audiologist
License Number
License Number StateMI
# 4
Primary TaxonomyN
Taxonomy Code235500000X
TaxonomySpeech/Language/Hearing Specialist/Technologist
License Number
License Number StateMI
# 5
Primary TaxonomyN
Taxonomy Code2355A2700X
TaxonomyAudiology Assistant
License Number
License Number StateMI
# 6
Primary TaxonomyN
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License Number
License Number StateMI
# 7
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number StateMI
# 8
Primary TaxonomyN
Taxonomy Code237600000X
TaxonomyAudiologist-Hearing Aid Fitter
License Number
License Number StateMI
# 9
Primary TaxonomyN
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number
License Number StateMI

VIII. Authorized Official

Name: SANDRA WHITMAN
Title or Position: DIRECTOR
Credential:
Phone: 248-849-4229