MEDICARE: ST JOHN MEDICAL CENTER MACOMB TOWNSHIP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QU0200X	Urgent Care Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0E01417	OTHER	MI	BLUE CARE NETWORK PIN

General Provider Information

NPI Number	:	1083746820
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ST JOHN MEDICAL CENTER MACOMB TOWNSHIP

Provider Business Mailing Address
First Line	:	28000 DEQUINDRE RD
Second Line	:
City	:	WARREN
State	:	MI
Zip	:	48092-2468
Country	:	US
Telephone Number	:	586-753-0011
Fax Number	:

Provider Business Practice Location Address
First Line	:	17700 23 MILE RD
Second Line	:
City	:	MACOMB
State	:	MI
Zip	:	48044-1154
Country	:	US
Telephone Number	:	586-753-0011
Fax Number	:

Authorized Official
Title or Position	:	CFO
Name	:	MS. TOMASINE MARX
Credential	:
Telephone Number	:	313-343-7676

Provider Enumeration Date	:	03/09/2007
Last Update Date	:	12/03/2010

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Directions to “ST JOHN MEDICAL CENTER MACOMB TOWNSHIP ” Practice Location

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