Basic Information
| Provider Information | |||||||||
| NPI: | 1720180169 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SJMH MEDICAL PRACTICE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 44428 WOODWARD AVE | ||||||||
| Address2: | LOWER LEVEL | ||||||||
| City: | PONTIAC | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483415009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2488586144 | ||||||||
| FaxNumber: | 2488586232 | ||||||||
| Practice Location | |||||||||
| Address1: | 44405 WOODWARD AVE | ||||||||
| Address2: | |||||||||
| City: | PONTIAC | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483415023 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2488583991 | ||||||||
| FaxNumber: | 2488586232 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/05/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | WEINER | ||||||||
| AuthorizedOfficialFirstName: | JACK | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2488583140 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
No ID Information.