Basic Information
| Provider Information | |||||||||
| NPI: | 1255451456 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ST JOHN HEALTH SYSTEM | ||||||||
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| OtherOrganizationName: | ST JOHN HEALTH CHRONIC HEADACHE AND MIGRAINE INSTITUTE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 25925 TELEGRAPH RD | ||||||||
| Address2: | 210 | ||||||||
| City: | SOUTHFIELD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480342518 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2487463218 | ||||||||
| FaxNumber: | 2487460369 | ||||||||
| Practice Location | |||||||||
| Address1: | 27483 DEQUINDRE RD | ||||||||
| Address2: | SUITE 306 | ||||||||
| City: | MADISON HEIGHTS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480713491 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2489677988 | ||||||||
| FaxNumber: | 2489677991 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/30/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | WHITMAN | ||||||||
| AuthorizedOfficialFirstName: | SANDRA | ||||||||
| AuthorizedOfficialMiddleName: | ELLEN | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR-PHYSICIAN BILLING SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 2487463218 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | 103TB0200X | X | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Cognitive & Behavioral |
ID Information
| ID | Type | State | Issuer | Description | 680F33073 | 01 | MI | BCBSM GROUP PIN | OTHER |