Provider Demographics
NPI:1568559227
Name:ST. JOHN HEALTH SYSTEM - MACOMB
Entity Type:Organization
Organization Name:ST. JOHN HEALTH SYSTEM - MACOMB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACUTE CARE NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:TODD
Authorized Official - Middle Name:MARSHALL
Authorized Official - Last Name:ROARK
Authorized Official - Suffix:
Authorized Official - Credentials:NURSE PRACTITIONER
Authorized Official - Phone:586-573-5402
Mailing Address - Street 1:333 E MAPLEHURST ST
Mailing Address - Street 2:
Mailing Address - City:FERNDALE
Mailing Address - State:MI
Mailing Address - Zip Code:48220-1374
Mailing Address - Country:US
Mailing Address - Phone:248-259-6615
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:586-573-5402
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704229946282NC0060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access