1720111701 NPI number — ST JOHN HOSPITAL CORPORATION

Table of content: (NPI 1720111701)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720111701 NPI number — ST JOHN HOSPITAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ST JOHN HOSPITAL CORPORATION
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 REGISTERED DIETICIAN 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:
1720111701
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/12/2007
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:
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:
586-228-4635
Provider Business Mailing Address Fax Number:
586-228-4520

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
22101 MOROSS RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DETROIT
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48236-2148
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
586-228-4635
Provider Business Practice Location Address Fax Number:
586-228-4520
Provider Enumeration Date:
03/13/2007

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
Authorized Official Telephone Number:
586-226-6823

Provider Taxonomy Codes

  • Taxonomy code: 133V00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: OQ262160 . This is a "BCBSM GROUP" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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