Provider Demographics
NPI:1376854661
Name:ST. JOHN HOSPITAL AND MEDICAL CENTER
Entity Type:Organization
Organization Name:ST. JOHN HOSPITAL AND MEDICAL CENTER
Other - Org Name:MEDICAL RESOURCES GROUP NURSE PRACTITIONERS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-680-8206
Mailing Address - Street 1:2800 LIVERNOIS RD
Mailing Address - Street 2:SUITE 500
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48083-1215
Mailing Address - Country:US
Mailing Address - Phone:248-680-8000
Mailing Address - Fax:248-680-8031
Practice Address - Street 1:2800 LIVERNOIS RD
Practice Address - Street 2:SUITE 500
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48083-1215
Practice Address - Country:US
Practice Address - Phone:248-680-8000
Practice Address - Fax:248-680-8031
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-01
Last Update Date:2016-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty