Basic Information
| Provider Information | |||||||||
| NPI: | 1154423598 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SJMH MEDICAL PRACTICE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 44405 WOODWARD AVE | ||||||||
| Address2: | |||||||||
| City: | PONTIAC | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483415023 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2488583526 | ||||||||
| FaxNumber: | 2488586232 | ||||||||
| Practice Location | |||||||||
| Address1: | 44405 WOODWARD AVE | ||||||||
| Address2: | |||||||||
| City: | PONTIAC | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483415023 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2488583526 | ||||||||
| FaxNumber: | 2488586232 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/05/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | WEINER | ||||||||
| AuthorizedOfficialFirstName: | JACK | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2488583140 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 2080N0001X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Neonatal-Perinatal Medicine | 2080P0203X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Critical Care Medicine | 2080P0204X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Emergency Medicine |
No ID Information.