Provider Demographics
NPI:1750470589
Name:ST JOHN DETROIT MACOMB HOSPITAL CORPORATION
Entity Type:Organization
Organization Name:ST JOHN DETROIT MACOMB HOSPITAL CORPORATION
Other - Org Name:ST JOHN WEIGHT LOSS CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR PBS
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:248-746-3218
Mailing Address - Street 1:25925 TELEGRAPH RD
Mailing Address - Street 2:210
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48034-2518
Mailing Address - Country:US
Mailing Address - Phone:248-746-3218
Mailing Address - Fax:248-746-0369
Practice Address - Street 1:27483 DEQUINDRE RD
Practice Address - Street 2:204
Practice Address - City:MADISON HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48071-3491
Practice Address - Country:US
Practice Address - Phone:248-967-7326
Practice Address - Fax:248-967-7330
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-12
Last Update Date:2007-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI70-0H2015300OtherBLUE CROSS GROUP PIN
MI70-0H2015300OtherBLUE CROSS GROUP PIN