Basic Information
| Provider Information | |||||||||
| NPI: | 1063602092 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ST MARY MERCY HOSPITAL CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 36475 5 MILE RD | ||||||||
| Address2: | |||||||||
| City: | LIVONIA | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481541971 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7346554800 | ||||||||
| FaxNumber: | 7346551274 | ||||||||
| Practice Location | |||||||||
| Address1: | 36475 5 MILE RD | ||||||||
| Address2: | ATTN PATIEINT ACCOUNTING | ||||||||
| City: | LIVONIA | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481541971 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7346554800 | ||||||||
| FaxNumber: | 7346551274 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2007 | ||||||||
| LastUpdateDate: | 11/03/2015 | ||||||||
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| AuthorizedOfficialLastName: | SPIVEY | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT & CEO | ||||||||
| AuthorizedOfficialTelephone: | 7346551610 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ST MARY MERCY HOSPITAL | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 820190 | MI | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 430H233570 | 01 | MI | BLUE SHIELD | OTHER |