Basic Information
| Provider Information | |||||||||
| NPI: | 1356525562 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MEDICAL RESOURCE GROUP | ||||||||
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| OtherOrganizationName: | ST. JOHN WEIGHT LOSS INSTITUTE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 43750 GARFIELD RD | ||||||||
| Address2: | SUITE 211 | ||||||||
| City: | CLINTON TOWNSHIP | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480381135 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8779969975 | ||||||||
| FaxNumber: | 5862284533 | ||||||||
| Practice Location | |||||||||
| Address1: | 45660 SCHOENHERR RD | ||||||||
| Address2: | |||||||||
| City: | SHELBY TOWNSHIP | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483156033 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8669963066 | ||||||||
| FaxNumber: | 5865663068 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/24/2007 | ||||||||
| LastUpdateDate: | 12/24/2007 | ||||||||
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| AuthorizedOfficialLastName: | JOHNSON | ||||||||
| AuthorizedOfficialFirstName: | JENNIFER | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5862284560 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | MI | Y | 193400000X SINGLE SPECIALTY GROUP | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.