Healthcare Provider Details

I. General information

NPI: 1730182247
Provider Name (Legal Business Name): JOHN M. STAFFORD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/30/2005
Last Update Date: 11/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3800 HOLLYWOOD RD STE 101 ROYALTON MEDICAL CENTER
SAINT JOSEPH MI
49085-8511
US

IV. Provider business mailing address

3800 HOLLYWOOD RD STE 101 ROYALTON MEDICAL CENTER
SAINT JOSEPH MI
49085-8511
US

V. Phone/Fax

Practice location:
  • Phone: 269-428-2552
  • Fax: 269-428-2943
Mailing address:
  • Phone: 269-428-2552
  • Fax: 269-428-2943

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4301044515
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: