Provider Demographics
NPI:1043478910
Name:ASCENSION ST JOHN HOSPITAL
Entity Type:Organization
Organization Name:ASCENSION ST JOHN HOSPITAL
Other - Org Name:ST JOHN NORTH SHORES HOSPITAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:J
Authorized Official - Last Name:PALAZZOLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-343-3558
Mailing Address - Street 1:28000 DEQUINDRE RD
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48092-2468
Mailing Address - Country:US
Mailing Address - Phone:586-753-0275
Mailing Address - Fax:
Practice Address - Street 1:26755 BALLARD ST
Practice Address - Street 2:
Practice Address - City:HARRISON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48045-2419
Practice Address - Country:US
Practice Address - Phone:584-655-5501
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-28
Last Update Date:2018-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0E0110OtherBLUE CROSS
0E0110OtherBLUE CROSS