Basic Information
| Provider Information | |||||||||
| NPI: | 1063854941 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MEDICAL RESOURCE GROUP | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | ST. JOHN EASTSIDE URGENT CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 21000 E 12 MILE RD | ||||||||
| Address2: | SUITE 105 | ||||||||
| City: | SAINT CLAIR SHORES | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480811116 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5864983606 | ||||||||
| FaxNumber: | 5864983601 | ||||||||
| Practice Location | |||||||||
| Address1: | 21000 E 12 MILE RD | ||||||||
| Address2: | SUITE 105 | ||||||||
| City: | SAINT CLAIR SHORES | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480811116 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5864983606 | ||||||||
| FaxNumber: | 5864983601 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/22/2013 | ||||||||
| LastUpdateDate: | 07/22/2013 | ||||||||
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| AuthorizedOfficialLastName: | JOHNSON | ||||||||
| AuthorizedOfficialFirstName: | JENNIFER | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5862284560 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QU0200X | MI | Y | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care |
No ID Information.