Provider Demographics
NPI:1639203482
Name:DETROIT-MACOMB HOSPITAL CORPORATION
Entity Type:Organization
Organization Name:DETROIT-MACOMB HOSPITAL CORPORATION
Other - Org Name:ST. JOHN RIVERVIEW HOSPITAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR PHYSICIAN SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:ELLEN
Authorized Official - Last Name:WHITMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-746-5822
Mailing Address - Street 1:43800 GARFIELD
Mailing Address - Street 2:201
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48038
Mailing Address - Country:US
Mailing Address - Phone:586-228-4635
Mailing Address - Fax:586-228-4520
Practice Address - Street 1:7815 E. JEFFERSON
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48214
Practice Address - Country:US
Practice Address - Phone:313-499-4170
Practice Address - Fax:313-499-4911
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice MidwifeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOH225770OtherBCBSM GRP CNM
MIOP15670Medicare PIN