Provider Demographics
NPI:1871896332
Name:ST. JOHN MACOMB-OAKLAND HOSPITAL
Entity type:Organization
Organization Name:ST. JOHN MACOMB-OAKLAND HOSPITAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:877-996-9975
Mailing Address - Street 1:27450 SCHOENHERR RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48088-6683
Mailing Address - Country:US
Mailing Address - Phone:586-582-7860
Mailing Address - Fax:586-582-7861
Practice Address - Street 1:27450 SCHOENHERR RD
Practice Address - Street 2:SUITE 200
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48088-6683
Practice Address - Country:US
Practice Address - Phone:586-582-7860
Practice Address - Fax:586-582-7861
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-06
Last Update Date:2010-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI207T00000X, 207W00000X, 208200000X, 2086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
No207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Multi-Specialty
No208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Multi-Specialty
No2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MICG3113OtherRAILROAD MEDICARE GROUP NUMBER
MI180E01180OtherBCBS GROUP NUMBER
MICG3113OtherRAILROAD MEDICARE GROUP NUMBER