Basic Information
| Provider Information | |||||||||
| NPI: | 1366644551 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SJMH MEDICAL PRACTICE-SMHC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | SJMH URGENT CARES | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 44428 WOODWARD AVE | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | PONTIAC | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483415009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2488583015 | ||||||||
| FaxNumber: | 2488586232 | ||||||||
| Practice Location | |||||||||
| Address1: | 4400 HIGHLAND RD | ||||||||
| Address2: | |||||||||
| City: | WATERFORD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483281222 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2486732474 | ||||||||
| FaxNumber: | 2486180355 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2007 | ||||||||
| LastUpdateDate: | 05/24/2019 | ||||||||
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| AuthorizedOfficialLastName: | STRIEBICH | ||||||||
| AuthorizedOfficialFirstName: | SHANNON | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2488583140 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QU0200X | Y | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care |
No ID Information.