Basic Information
| Provider Information | |||||||||
| NPI: | 1740312685 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ST JOHN HOSPITAL AND MEDICAL CENTER | ||||||||
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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: | 26755 BALLARD ST | ||||||||
| Address2: | |||||||||
| City: | HARRISON TOWNSHIP | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480452419 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5837530011 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/09/2007 | ||||||||
| LastUpdateDate: | 04/22/2010 | ||||||||
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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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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 0E01105 | 01 | MI | BCBSM PIN | OTHER |