Provider Demographics
NPI:1942564588
Name:ST JOHN HOSPITAL AND MEDICAL CENTRE
Entity Type:Organization
Organization Name:ST JOHN HOSPITAL AND MEDICAL CENTRE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:E
Authorized Official - Last Name:MINNICK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:313-343-3875
Mailing Address - Street 1:22151 MOROSS RD
Mailing Address - Street 2:PBI STE.311
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48236-2167
Mailing Address - Country:US
Mailing Address - Phone:786-218-8208
Mailing Address - Fax:
Practice Address - Street 1:22151 MOROSS RD
Practice Address - Street 2:PBI STE.311
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48236-2167
Practice Address - Country:US
Practice Address - Phone:786-218-8208
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-28
Last Update Date:2012-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301096422207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty