Basic Information
| Provider Information | |||||||||
| NPI: | 1134729114 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ST JOSEPH MERCY HOSPITAL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 20555 VICTOR PKWY | ||||||||
| Address2: | |||||||||
| City: | LIVONIA | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481527031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7347123456 | ||||||||
| FaxNumber: | 3129572834 | ||||||||
| Practice Location | |||||||||
| Address1: | 5301 E HURON RIVER DR | ||||||||
| Address2: | |||||||||
| City: | YPSILANTI | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481971051 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7347123456 | ||||||||
| FaxNumber: | 7347120013 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/28/2020 | ||||||||
| LastUpdateDate: | 10/28/2020 | ||||||||
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| AuthorizedOfficialLastName: | GUSHO | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | PAUL | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 2488586174 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | HOSPITAL AT HOME | ||||||||
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| AuthorizedOfficialCredential: | CFO | ||||||||
| NPICertificationDate: | 10/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 230156 | 05 | MI | MEDICAID | 230156 | 01 | MI | MEDICARE | OTHER |