Basic Information
| Provider Information | |||||||||
| NPI: | 1851362586 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ST. JOHN HOSPITAL AND MEDICAL CENTER | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | ST. JOHN NORTH SHORES HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 28000 DEQUINDRE ROAD | ||||||||
| Address2: | |||||||||
| City: | WARREN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480922468 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5867530275 | ||||||||
| FaxNumber: | 5867530286 | ||||||||
| Practice Location | |||||||||
| Address1: | 26755 BALLARD ROAD | ||||||||
| Address2: | |||||||||
| City: | HARRISON TOWNSHIP | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48045 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5864655501 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/31/2006 | ||||||||
| LastUpdateDate: | 06/11/2008 | ||||||||
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| AuthorizedOfficialLastName: | PALAZZOLO | ||||||||
| AuthorizedOfficialFirstName: | CHRISTOPHER | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | VP FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 3133433558 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 00248 | 01 | BLUE CROSS | OTHER |