Provider Demographics
NPI:1952397226
Name:ST. MICHAEL NURSING CENTER
Entity Type:Organization
Organization Name:ST. MICHAEL NURSING CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:A
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-892-3600
Mailing Address - Street 1:19175 ANGLIN ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48234-1407
Mailing Address - Country:US
Mailing Address - Phone:313-892-3600
Mailing Address - Fax:313-892-5624
Practice Address - Street 1:19175 ANGLIN ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48234-1407
Practice Address - Country:US
Practice Address - Phone:313-892-3600
Practice Address - Fax:313-892-5624
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI834031314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3178479Medicaid
MI235610Medicare ID - Type Unspecified