Basic Information
| Provider Information | |||||||||
| NPI: | 1013649557 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ST MARY MERCY HOSPITAL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | TRINITY HEALTH ST. MARY MERCY LIVONIA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 20555 VICTOR PKWY | ||||||||
| Address2: | |||||||||
| City: | LIVONIA | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481527031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7343433925 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 36475 FIVE MILE RD | ||||||||
| Address2: | |||||||||
| City: | LIVONIA | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481541971 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7346554800 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2022 | ||||||||
| LastUpdateDate: | 07/19/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GUSHO | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | PAUL | ||||||||
| AuthorizedOfficialTitleorPosition: | REGIONAL CFO | ||||||||
| AuthorizedOfficialTelephone: | 2316723886 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 07/19/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WD0400X | Y | 193400000X SINGLE SPECIALTY GROUP | Nursing Service Providers | Registered Nurse | Diabetes Educator |
No ID Information.