Basic Information
| Provider Information | |||||||||
| NPI: | 1629741095 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ST MARY MERCY HOSPITAL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 20555 VICTOR PKWY | ||||||||
| Address2: | |||||||||
| City: | LIVONIA | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481527031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7343433925 | ||||||||
| FaxNumber: | 3129573997 | ||||||||
| Practice Location | |||||||||
| Address1: | 19000 ST JOES PKWY STE 100 | ||||||||
| Address2: | |||||||||
| City: | LIVONIA | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481521477 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7347434656 | ||||||||
| FaxNumber: | 7347434369 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/30/2021 | ||||||||
| LastUpdateDate: | 07/30/2021 | ||||||||
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| AuthorizedOfficialLastName: | GUSHO | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | PAUL | ||||||||
| AuthorizedOfficialTitleorPosition: | REGIONAL CFO | ||||||||
| AuthorizedOfficialTelephone: | 7343980642 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 07/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
No ID Information.