Basic Information
| Provider Information | |||||||||
| NPI: | 1750470589 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ST JOHN DETROIT MACOMB HOSPITAL CORPORATION | ||||||||
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| OtherOrganizationName: | ST JOHN WEIGHT LOSS CENTER | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 25925 TELEGRAPH RD | ||||||||
| Address2: | 210 | ||||||||
| City: | SOUTHFIELD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480342518 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2487463218 | ||||||||
| FaxNumber: | 2487460369 | ||||||||
| Practice Location | |||||||||
| Address1: | 27483 DEQUINDRE RD | ||||||||
| Address2: | 204 | ||||||||
| City: | MADISON HEIGHTS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480713491 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2489677326 | ||||||||
| FaxNumber: | 2489677330 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2006 | ||||||||
| LastUpdateDate: | 08/08/2007 | ||||||||
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| AuthorizedOfficialLastName: | WHITMAN | ||||||||
| AuthorizedOfficialFirstName: | SANDRA | ||||||||
| AuthorizedOfficialMiddleName: | ELLEN | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR PBS | ||||||||
| AuthorizedOfficialTelephone: | 2487463218 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 70-0H2015300 | 01 | MI | BLUE CROSS GROUP PIN | OTHER |