Provider Demographics
NPI:1417983990
Name:ST. JOHN MACOMB-OAKLAND HOSPITAL
Entity Type:Organization
Organization Name:ST. JOHN MACOMB-OAKLAND HOSPITAL
Other - Org Name:MRI CENTER OAKLAND
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:877-996-9975
Mailing Address - Street 1:43750 GARFIELD RD
Mailing Address - Street 2:SUITE 211
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-1135
Mailing Address - Country:US
Mailing Address - Phone:586-228-4652
Mailing Address - Fax:586-228-4533
Practice Address - Street 1:27379 DEQUINDRE RD
Practice Address - Street 2:
Practice Address - City:MADISON HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48071-3487
Practice Address - Country:US
Practice Address - Phone:248-398-4488
Practice Address - Fax:248-398-4994
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-25
Last Update Date:2011-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2085R0202X, 261QM1200X, 261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1200XAmbulatory Health Care FacilitiesClinic/CenterMagnetic Resonance Imaging (MRI)Group - Multi-Specialty
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
No261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI300F301350OtherBCBS GROUP NUMBER
MIDA0334OtherRAILROAD MEDICARE GROUP NUMBER
MI300F301350OtherBCBS GROUP NUMBER