Provider Demographics
NPI:1922276013
Name:SJMO BALD MOUNTAIN
Entity Type:Organization
Organization Name:SJMO BALD MOUNTAIN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JACK
Authorized Official - Middle Name:
Authorized Official - Last Name:WEINER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-858-3140
Mailing Address - Street 1:1375 S LAPEER RD
Mailing Address - Street 2:SUITE 160
Mailing Address - City:LAKE ORION
Mailing Address - State:MI
Mailing Address - Zip Code:48360-1421
Mailing Address - Country:US
Mailing Address - Phone:248-693-9040
Mailing Address - Fax:248-693-9007
Practice Address - Street 1:1375 S LAPEER RD
Practice Address - Street 2:SUITE 160
Practice Address - City:LAKE ORION
Practice Address - State:MI
Practice Address - Zip Code:48360-1421
Practice Address - Country:US
Practice Address - Phone:248-693-9040
Practice Address - Fax:248-693-9007
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TRINITY HEALTH-MICHIGAN
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-02-12
Last Update Date:2008-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty