Basic Information
| Provider Information | |||||||||
| NPI: | 1174721740 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SAINT JOSEPH LIVINGSTON HOSPITAL | ||||||||
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| OtherOrganizationName: | TRINITY HEALTH - MICHIGAN | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 620 BYRON RD | ||||||||
| Address2: | |||||||||
| City: | HOWELL | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488431002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5175456000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2300 GENOA BUSINESS PARK DR STE 180 | ||||||||
| Address2: | |||||||||
| City: | BRIGHTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481147374 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7347862300 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2007 | ||||||||
| LastUpdateDate: | 08/30/2022 | ||||||||
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| AuthorizedOfficialLastName: | GUSHO | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | PAUL | ||||||||
| AuthorizedOfficialTitleorPosition: | REGIONAL CFO | ||||||||
| AuthorizedOfficialTelephone: | 2316723886 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 08/30/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 276400000X | 470079 | MI | Y | Hospital Units | Rehabilitation, Substance Use Disorder Unit |
ID Information
| ID | Type | State | Issuer | Description | 20210 | 01 | MI | BLUE CROSS OP SUB ABUSE | OTHER |