Basic Information
Provider Information | |||||||||
NPI: | 1700815347 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ST JOSEPH MERCY CHELSEA INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | ST. JOSEPH MERCY CHELSEA | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 34505 W 12 MILE RD STE 200 | ||||||||
Address2: |   | ||||||||
City: | FARMINGTON HILLS | ||||||||
State: | MI | ||||||||
PostalCode: | 483313286 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7343433922 | ||||||||
FaxNumber: | 3129572766 | ||||||||
Practice Location | |||||||||
Address1: | 775 S MAIN ST | ||||||||
Address2: |   | ||||||||
City: | CHELSEA | ||||||||
State: | MI | ||||||||
PostalCode: | 481181383 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7345936000 | ||||||||
FaxNumber: | 7345935365 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/03/2006 | ||||||||
LastUpdateDate: | 05/13/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | LOCKARD | ||||||||
AuthorizedOfficialFirstName: | SUSAN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | SR REVENUE MANAGEMENT ANALYST | ||||||||
AuthorizedOfficialTelephone: | 7343430282 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273R00000X |   |   | Y |   | Hospital Units | Psychiatric Unit |   |
ID Information
ID | Type | State | Issuer | Description | MCARE | 01 | MI | HL81007 | OTHER | HEALTH ALLIANCE PLAN | 01 | MI | 230259 | OTHER | CARE CHOICES | 01 | MI | 100084 | OTHER | BLUE CROSS | 01 | MI | 00252 | OTHER |