Basic Information
| Provider Information | |||||||||
| NPI: | 1225306392 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ST MARY MERCY PHYSICIAN PRACTICES | ||||||||
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| OtherOrganizationName: | ST MARY MERCY ONCOLOGY PRACTICE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 20555 VICTOR PKWY | ||||||||
| Address2: | SE MI SHARED SERVICES W3D | ||||||||
| City: | LIVONIA | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481527031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7343430282 | ||||||||
| FaxNumber: | 2483804445 | ||||||||
| Practice Location | |||||||||
| Address1: | 14555 LEVAN RD | ||||||||
| Address2: | SUITE 112 | ||||||||
| City: | LIVONIA | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481545083 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7347792123 | ||||||||
| FaxNumber: | 7347792163 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/05/2011 | ||||||||
| LastUpdateDate: | 11/03/2015 | ||||||||
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| AuthorizedOfficialLastName: | SPIVEY | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT / CEO | ||||||||
| AuthorizedOfficialTelephone: | 7346551610 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ST MARY MERCY PHYSICIAN PRACTICES | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QX0200X | Y | Ambulatory Health Care Facilities | Clinic/Center | Oncology |
ID Information
| ID | Type | State | Issuer | Description | 0H27566 | 01 | MI | BLUE SHIELD PIN | OTHER |