Basic Information
| Provider Information | |||||||||
| NPI: | 1336353663 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ST JOSEPH MERCY HOSPITAL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 34505 W 12 MILE RD STE 200 | ||||||||
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| City: | FARMINGTON HILLS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483313286 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7343433922 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2004 HOGBACK RD | ||||||||
| Address2: | SUITE 16 | ||||||||
| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481059738 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7347123456 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/09/2007 | ||||||||
| LastUpdateDate: | 10/05/2017 | ||||||||
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| AuthorizedOfficialLastName: | GUSHO | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO SE MI REGION | ||||||||
| AuthorizedOfficialTelephone: | 2488586174 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | 103TP0016X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Prescribing (Medical) | 1041C0700X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 106H00000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 2084P0800X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 10433 | 01 | MI | BLUE CROSS | OTHER |