Basic Information
| Provider Information | |||||||||
| NPI: | 1083746820 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ST JOHN MEDICAL CENTER MACOMB TOWNSHIP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 28000 DEQUINDRE RD | ||||||||
| Address2: | |||||||||
| City: | WARREN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480922468 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5867530011 | ||||||||
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| Practice Location | |||||||||
| Address1: | 17700 23 MILE RD | ||||||||
| Address2: | |||||||||
| City: | MACOMB | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480441154 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5867530011 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/09/2007 | ||||||||
| LastUpdateDate: | 12/03/2010 | ||||||||
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| AuthorizedOfficialLastName: | MARX | ||||||||
| AuthorizedOfficialFirstName: | TOMASINE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 3133437676 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QU0200X | Y | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care |
ID Information
| ID | Type | State | Issuer | Description | 0E01417 | 01 | MI | BLUE CARE NETWORK PIN | OTHER |