MEDICARE: ST. JOHN HOSPITAL AND MEDICAL CENTER

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	282N00000X	General Acute Care Hospital

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	00248	OTHER		BLUE CROSS

General Provider Information

NPI Number	:	1851362586
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ST. JOHN HOSPITAL AND MEDICAL CENTER

Provider Business Mailing Address
First Line	:	28000 DEQUINDRE ROAD
Second Line	:
City	:	WARREN
State	:	MI
Zip	:	48092-2468
Country	:	US
Telephone Number	:	586-753-0275
Fax Number	:	586-753-0286

Provider Business Practice Location Address
First Line	:	26755 BALLARD ROAD
Second Line	:
City	:	HARRISON TOWNSHIP
State	:	MI
Zip	:	48045
Country	:	US
Telephone Number	:	586-465-5501
Fax Number	:

Authorized Official
Title or Position	:	VP FINANCE
Name	:	CHRISTOPHER J PALAZZOLO
Credential	:
Telephone Number	:	313-343-3558

Provider Enumeration Date	:	01/31/2006
Last Update Date	:	06/11/2008

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