1174549018 NPI number — ST JOHN HEALTH SYSTEM- DETROIT-MACOMB CAMPUS

Table of content: (NPI 1174549018)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174549018 NPI number — ST JOHN HEALTH SYSTEM- DETROIT-MACOMB CAMPUS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ST JOHN HEALTH SYSTEM- DETROIT-MACOMB CAMPUS
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
MACOMB SURGICAL GROUP
Provider Other Organization Name Type Code:
5
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1174549018
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/14/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
43800 GARFIELD RD
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
CLINTON TOWNSHIP
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48038-1136
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-848-0202
Provider Business Mailing Address Fax Number:
586-226-6949

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11800 E 12 MILE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WARREN
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48093-3472
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
586-573-5000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/14/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WHITMAN
Authorized Official First Name:
SANDRA
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
586-226-6823

Provider Taxonomy Codes

  • Taxonomy code: 208600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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