Provider Demographics
NPI:1922088624
Name:JOH, MICHAEL M (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:M
Last Name:JOH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36175 HARPER AVE
Mailing Address - Street 2:
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48035-3274
Mailing Address - Country:US
Mailing Address - Phone:586-741-3772
Mailing Address - Fax:586-741-4604
Practice Address - Street 1:36175 HARPER AVE
Practice Address - Street 2:
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48035-3274
Practice Address - Country:US
Practice Address - Phone:586-741-3772
Practice Address - Fax:586-741-4604
Is Sole Proprietor?:No
Enumeration Date:2006-01-19
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301031473207U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207U00000XAllopathic & Osteopathic PhysiciansNuclear Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0H26188OtherBCBS PROVIDER NUMBER
MI3376260Medicaid
MI1006439OtherMCLAREN HEALTH
MI111261OtherGREAT LAKES HEALTH
MI0Q26008OtherBCBS PROVIDER NUMBER
MI0H26188OtherBCBS PROVIDER NUMBER
MI111261OtherGREAT LAKES HEALTH
MIB43638Medicare UPIN