Basic Information
| Provider Information | |||||||||
| NPI: | 1831220797 | ||||||||
| 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: | 24911 LITTLE MACK AVE | ||||||||
| Address2: | SUITE C | ||||||||
| City: | SAINT CLAIR SHORES | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480803200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5867530011 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/09/2007 | ||||||||
| LastUpdateDate: | 06/10/2009 | ||||||||
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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 | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 261Q00000X | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | 0E07766 | 01 | MI | BCBSM PIN | OTHER |