1255451456 NPI number — ST JOHN HEALTH SYSTEM

Table of content: (NPI 1255451456)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255451456 NPI number — ST JOHN HEALTH SYSTEM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ST JOHN HEALTH SYSTEM
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:
ST JOHN HEALTH CHRONIC HEADACHE AND MIGRAINE INSTITUTE
Provider Other Organization Name Type Code:
3
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:
1255451456
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
25925 TELEGRAPH RD
Provider Second Line Business Mailing Address:
210
Provider Business Mailing Address City Name:
SOUTHFIELD
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48034-2518
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-746-3218
Provider Business Mailing Address Fax Number:
248-746-0369

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
27483 DEQUINDRE RD
Provider Second Line Business Practice Location Address:
SUITE 306
Provider Business Practice Location Address City Name:
MADISON HEIGHTS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48071-3491
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-967-7988
Provider Business Practice Location Address Fax Number:
248-967-7991
Provider Enumeration Date:
03/30/2007

Additional Information

Authorized Official

Authorized Official Last Name:
WHITMAN
Authorized Official First Name:
SANDRA
Authorized Official Middle Name:
ELLEN
Authorized Official Title or Position:
DIRECTOR-PHYSICIAN BILLING SERVICES
Authorized Official Telephone Number:
248-746-3218

Provider Taxonomy Codes

  • Taxonomy code: 103TB0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 208600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

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

  • Identifier: 680F33073 . This is a "BCBSM GROUP PIN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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