Basic Information
| Provider Information | |||||||||
| NPI: | 1568630077 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ST MARY MERCY PHYSICIAN PRACTICES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 20555 VICTOR PKWY | ||||||||
| Address2: | ATTN: SE MI SHARED SERVICESW3D CHETRINITY HEALTH | ||||||||
| City: | LIVONIA | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481527031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7343430282 | ||||||||
| FaxNumber: | 2483804445 | ||||||||
| Practice Location | |||||||||
| Address1: | 36475 5 MILE RD | ||||||||
| Address2: | |||||||||
| City: | LIVONIA | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481541971 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7346554800 | ||||||||
| FaxNumber: | 7346552609 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/19/2008 | ||||||||
| LastUpdateDate: | 11/03/2015 | ||||||||
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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 | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
ID Information
| ID | Type | State | Issuer | Description | 010H233560 | 01 | MI | BCBS-MI PIN | OTHER |