Provider Demographics
NPI:1720111701
Name:ST JOHN HOSPITAL CORPORATION
Entity Type:Organization
Organization Name:ST JOHN HOSPITAL CORPORATION
Other - Org Name:ST JOHN REGISTERED DIETICIAN GROUP
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:ELLEN
Authorized Official - Last Name:WHITMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:586-226-6823
Mailing Address - Street 1:43800 GARFIELD RD
Mailing Address - Street 2:200
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-1136
Mailing Address - Country:US
Mailing Address - Phone:586-228-4635
Mailing Address - Fax:586-228-4520
Practice Address - Street 1:22101 MOROSS RD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48236-2148
Practice Address - Country:US
Practice Address - Phone:586-228-4635
Practice Address - Fax:586-228-4520
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-13
Last Update Date:2007-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOQ262160OtherBCBSM GROUP
MIOQ262160OtherBCBSM GROUP