Provider Demographics
NPI:1801866942
Name:ST. JOHN HOSPITAL AND MEDICAL CENTER
Entity Type:Organization
Organization Name:ST. JOHN HOSPITAL AND MEDICAL CENTER
Other - Org Name:ST JOHN NORTH SHORES HOSPITAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP FINANCE
Authorized Official - Prefix:MRS
Authorized Official - First Name:TOMASINE
Authorized Official - Middle Name:
Authorized Official - Last Name:MARX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-343-7676
Mailing Address - Street 1:28000 DEQUINDRE RD
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48092-2468
Mailing Address - Country:US
Mailing Address - Phone:586-753-0275
Mailing Address - Fax:586-753-0286
Practice Address - Street 1:26755 BALLARD ST
Practice Address - Street 2:
Practice Address - City:HARRISON TWP
Practice Address - State:MI
Practice Address - Zip Code:48045-2419
Practice Address - Country:US
Practice Address - Phone:586-465-5501
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-23
Last Update Date:2012-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273Y00000XHospital UnitsRehabilitation Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
23T165Medicare PIN