Basic Information
| Provider Information | |||||||||
| NPI: | 1740445337 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ST JOHN HOSPITAL AND MEDICAL CENTER | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | ROMEO PLANK DIAGNOSTIC CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 67000 | ||||||||
| Address2: | DEPARTMENT 184101 | ||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482670002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8779969975 | ||||||||
| FaxNumber: | 5862284533 | ||||||||
| Practice Location | |||||||||
| Address1: | 46591 ROMEO PLANK RD | ||||||||
| Address2: | SUITE 137 | ||||||||
| City: | MACOMB | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480445742 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5862266226 | ||||||||
| FaxNumber: | 5862266255 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/23/2008 | ||||||||
| LastUpdateDate: | 01/27/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | JOHNSON | ||||||||
| AuthorizedOfficialFirstName: | JENNIFER | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8779969975 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085D0003X | MI | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Neuroimaging | 2085N0700X | MI | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Neuroradiology | 2085N0904X | MI | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Nuclear Radiology | 2085P0229X | MI | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Pediatric Radiology | 2085R0204X | MI | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 2085U0001X | MI | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Ultrasound | 247100000X | MI | N | 193200000X MULTI-SPECIALTY GROUP | Technologists, Technicians & Other Technical Service Providers | Radiologic Technologist | 2471B0102X | MI | N | 193200000X MULTI-SPECIALTY GROUP | Technologists, Technicians & Other Technical Service Providers | Radiologic Technologist | Bone Densitometry | 2471C3402X | MI | N | 193200000X MULTI-SPECIALTY GROUP | Technologists, Technicians & Other Technical Service Providers | Radiologic Technologist | Radiography | 2471M2300X | MI | N | 193200000X MULTI-SPECIALTY GROUP | Technologists, Technicians & Other Technical Service Providers | Radiologic Technologist | Mammography | 2471N0900X | MI | N | 193200000X MULTI-SPECIALTY GROUP | Technologists, Technicians & Other Technical Service Providers | Radiologic Technologist | Nuclear Medicine Technology | 2471S1302X | MI | N | 193200000X MULTI-SPECIALTY GROUP | Technologists, Technicians & Other Technical Service Providers | Radiologic Technologist | Sonography | 2471V0105X | MI | N | 193200000X MULTI-SPECIALTY GROUP | Technologists, Technicians & Other Technical Service Providers | Radiologic Technologist | Vascular Sonography | 2085R0202X | MI | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 310E022080 | 01 | MI | BCBSM GROUP NUMBER | OTHER |