Basic Information
| Provider Information | |||||||||
| NPI: | 1447381231 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ASCENSION ST JOHN HOSPITAL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 28000 DEQUINDRE RD | ||||||||
| Address2: | |||||||||
| City: | WARREN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480922468 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5867530011 | ||||||||
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| Practice Location | |||||||||
| Address1: | 21000 E 12 MILE RD | ||||||||
| Address2: | |||||||||
| City: | SAINT CLAIR SHORES | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480811116 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5867530011 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/07/2007 | ||||||||
| LastUpdateDate: | 08/04/2020 | ||||||||
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| AuthorizedOfficialLastName: | PALAZZOLO | ||||||||
| AuthorizedOfficialFirstName: | CHRISTOPHER | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | V.P. - FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 3133433558 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 08/04/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | 40116 | 01 | MI | BCBSM PIN | OTHER |