MEDICARE: HENRY FORD HEALTH ST. JOHN HOSPITAL

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	367500000X	Certified Registered Nurse Anesthetist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0H26493	OTHER	MI	BCBSM PIN

General Provider Information

NPI Number	:	1598896995
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HENRY FORD HEALTH ST. JOHN HOSPITAL

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	:	22101 MOROSS RD
Second Line	:	SUITE 101
City	:	DETROIT
State	:	MI
Zip	:	48236-2148
Country	:	US
Telephone Number	:	586-753-0011
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR
Name	:	KIMBERLY CEBALT
Credential	:
Telephone Number	:	313-874-6764

Provider Enumeration Date	:	03/08/2007
Last Update Date	:	03/12/2026

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