Provider Demographics
NPI:1164584256
Name:ST. JOHN MACOMB HOSPITAL
Entity Type:Organization
Organization Name:ST. JOHN MACOMB HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OF CARDIOLOGY
Authorized Official - Prefix:DR
Authorized Official - First Name:LINGAREDDY
Authorized Official - Middle Name:
Authorized Official - Last Name:DEVIREDDY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:586-574-0890
Mailing Address - Street 1:25320 RONALD CT
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48237-1327
Mailing Address - Country:US
Mailing Address - Phone:248-543-3063
Mailing Address - Fax:
Practice Address - Street 1:11800 E 12 MILE RD
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48093-3472
Practice Address - Country:US
Practice Address - Phone:586-573-5512
Practice Address - Fax:586-573-5148
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601003607282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital