Basic Information
| Provider Information | |||||||||
| NPI: | 1417983990 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ST. JOHN MACOMB-OAKLAND HOSPITAL | ||||||||
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| OtherOrganizationName: | MRI CENTER OAKLAND | ||||||||
| 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: | 5862284652 | ||||||||
| FaxNumber: | 5862284533 | ||||||||
| Practice Location | |||||||||
| Address1: | 27379 DEQUINDRE RD | ||||||||
| Address2: | |||||||||
| City: | MADISON HEIGHTS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480713487 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2483984488 | ||||||||
| FaxNumber: | 2483984994 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/25/2006 | ||||||||
| LastUpdateDate: | 01/27/2011 | ||||||||
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| AuthorizedOfficialLastName: | JOHNSON | ||||||||
| AuthorizedOfficialFirstName: | JENNIFER | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8779969975 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0200X | MI | N | Ambulatory Health Care Facilities | Clinic/Center | Radiology | 2085R0202X | MI | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 261QM1200X | MI | Y | Ambulatory Health Care Facilities | Clinic/Center | Magnetic Resonance Imaging (MRI) |
ID Information
| ID | Type | State | Issuer | Description | 300F301350 | 01 | MI | BCBS GROUP NUMBER | OTHER | DA0334 | 01 | MI | RAILROAD MEDICARE GROUP NUMBER | OTHER |