Healthcare Provider Details

I. General information

NPI: 1154612745
Provider Name (Legal Business Name): ST. JOHN PROVIDENCE HEALTH SYSTEM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/29/2011
Last Update Date: 04/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11800 E 12 MILE RD
WARREN MI
48093-3472
US

IV. Provider business mailing address

11800 EAST TWELVE MILE ROAD
WARREN MI
48093
US

V. Phone/Fax

Practice location:
  • Phone: 586-573-5872
  • Fax: 586-573-5583
Mailing address:
  • Phone: 586-573-5872
  • Fax: 586-573-5583

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License Number6401007085
License Number StateMI

VIII. Authorized Official

Name: MRS. CHRISTINA MARIA POPE
Title or Position: BEHAVIORAL HEALTH INTAKE CLINICIAN
Credential: MA LPC
Phone: 586-573-5872