Provider Demographics
NPI:1851362586
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:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:J
Authorized Official - Last Name:PALAZZOLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-343-3558
Mailing Address - Street 1:28000 DEQUINDRE ROAD
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 ROAD
Practice Address - Street 2:
Practice Address - City:HARRISON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48045
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:2006-01-31
Last Update Date:2008-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
00248OtherBLUE CROSS
00248OtherBLUE CROSS