Basic Information
| Provider Information | |||||||||
| NPI: | 1033376538 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ST JOHN MACOMB OAKLAND HOSPITAL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 28000 DEQUINDRE RD | ||||||||
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| City: | WARREN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480922468 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5867530275 | ||||||||
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| Practice Location | |||||||||
| Address1: | 7733 E JEFFERSON AVE | ||||||||
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| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482143707 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3134994000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/21/2008 | ||||||||
| LastUpdateDate: | 06/25/2008 | ||||||||
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| AuthorizedOfficialLastName: | KRUMMLER | ||||||||
| AuthorizedOfficialFirstName: | RANDOLPH | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 5865735910 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine | 2084N0400X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207RC0000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 0H26326 | 01 | BLUE CROSS | OTHER | 18200032 | 01 | MI | BLUE CROSS | OTHER |