Provider Demographics
NPI:1275762106
Name:ST.JOHN HOSPITAL & MEDICAL CENTER
Entity Type:Organization
Organization Name:ST.JOHN HOSPITAL & MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MONA
Authorized Official - Middle Name:ABDULLAH
Authorized Official - Last Name:ALFARES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:312-823-7637
Mailing Address - Street 1:19251 MACK AVE STE 335
Mailing Address - Street 2:
Mailing Address - City:GROSSE POINTE WOODS
Mailing Address - State:MI
Mailing Address - Zip Code:48236-2895
Mailing Address - Country:US
Mailing Address - Phone:312-823-7637
Mailing Address - Fax:
Practice Address - Street 1:19251 MACK AVE STE 335
Practice Address - Street 2:
Practice Address - City:GROSSE POINTE WOODS
Practice Address - State:MI
Practice Address - Zip Code:48236-2895
Practice Address - Country:US
Practice Address - Phone:312-823-7637
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-13
Last Update Date:2009-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIL1598766261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty