Basic Information
| Provider Information | |||||||||
| NPI: | 1487773347 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SAINT JOSEPH MERCY SALINE HOSPITAL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5301 E HURON RIVER DR | ||||||||
| Address2: | PO BOX 993, MC 69504 | ||||||||
| City: | YPSILANTI | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481971051 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7347123456 | ||||||||
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| Practice Location | |||||||||
| Address1: | 400 W RUSSELL ST | ||||||||
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| City: | SALINE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481761183 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7344291500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2007 | ||||||||
| LastUpdateDate: | 09/21/2011 | ||||||||
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| AuthorizedOfficialLastName: | FAJA | ||||||||
| AuthorizedOfficialFirstName: | GARRY | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT CEO | ||||||||
| AuthorizedOfficialTelephone: | 7347123791 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0300X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine | 207V00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207RH0002X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Hospice and Palliative Medicine | 207ZP0105X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Clinical Pathology/Laboratory Medicine | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 207N00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology | 207ZP0007X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Molecular Genetic Pathology | 207ZP0102X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 700H161140 | 01 | MI | BS BCN PATH, LAB | OTHER | 110H113860 | 01 | BS BCN AOG SHS | OTHER |