Basic Information
| Provider Information | |||||||||
| NPI: | 1386913705 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ST MARY MERCY HOSPITAL PROFESSIONAL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5301 E HURON RIVER DR | ||||||||
| Address2: | MC 69504 | ||||||||
| City: | YPSILANTI | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481971051 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7348278883 | ||||||||
| FaxNumber: | 7348278822 | ||||||||
| Practice Location | |||||||||
| Address1: | 2006 HOGBACK RD | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481059750 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7347862300 | ||||||||
| FaxNumber: | 7347864915 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/14/2011 | ||||||||
| LastUpdateDate: | 01/29/2016 | ||||||||
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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 PROFESSIONAL | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 0H10674 | 01 | BCBSM PIN | OTHER |