Provider Demographics
NPI:1780661322
Name:TIMOTHY C ST. JOHN II
Entity Type:Organization
Organization Name:TIMOTHY C ST. JOHN II
Other - Org Name:HOUGHTON LAKE FOOT CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:ST JOHN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:989-366-8332
Mailing Address - Street 1:4310 LEONARD ST NW
Mailing Address - Street 2:SUITE 103
Mailing Address - City:WALKER
Mailing Address - State:MI
Mailing Address - Zip Code:49534-8447
Mailing Address - Country:US
Mailing Address - Phone:616-453-6329
Mailing Address - Fax:616-453-1725
Practice Address - Street 1:3179 W HOUGHTON LAKE DR
Practice Address - Street 2:
Practice Address - City:HOUGHTON LAKE
Practice Address - State:MI
Practice Address - Zip Code:48629-9256
Practice Address - Country:US
Practice Address - Phone:989-366-8332
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-24
Last Update Date:2010-01-04
Deactivation Date:2008-01-03
Deactivation Code:
Reactivation Date:2008-01-24
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3119585Medicaid
MI3119585Medicaid
MI1122290001Medicare NSC
MIU08311Medicare UPIN
MI5725001Medicare ID - Type Unspecified