Basic Information
| Provider Information | |||||||||
| NPI: | 1811102742 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ST JOHN MACOMB OAKLAND HOSPITAL | ||||||||
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| OtherOrganizationName: | ST JOHN MACOMB OAKLAND HOSPITAL MACOMB CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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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: | 11800 E 12 MILE RD | ||||||||
| Address2: | |||||||||
| City: | WARREN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480933472 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5865735000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/14/2007 | ||||||||
| LastUpdateDate: | 01/28/2009 | ||||||||
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| AuthorizedOfficialLastName: | KUMMLER | ||||||||
| AuthorizedOfficialFirstName: | RANDOLPH | ||||||||
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| AuthorizedOfficialTitleorPosition: | V.P. - FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 5865735910 | ||||||||
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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 | 207ZP0102X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology | 291U00000X | Y | Laboratories | Clinical Medical Laboratory |
ID Information
| ID | Type | State | Issuer | Description | 0E06262 | 01 | MI | BCBS PIN | OTHER |