Provider Demographics
NPI:1780854174
Name:ST JOHN HOSPITAL AND MEDICAL CENTER
Entity Type:Organization
Organization Name:ST JOHN HOSPITAL AND MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OF THE DEPARTMENT OF FM
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:BOLLIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:586-447-9081
Mailing Address - Street 1:21441 SLOAN DR
Mailing Address - Street 2:APT # 102 B
Mailing Address - City:HARPER WOODS
Mailing Address - State:MI
Mailing Address - Zip Code:48225-2428
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:24911 LITTLE MACK AVE
Practice Address - Street 2:SUITE C
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48080-3200
Practice Address - Country:US
Practice Address - Phone:586-447-9081
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-03
Last Update Date:2008-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301088641207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty