Basic Information
| Provider Information | |||||||||
| NPI: | 1730208778 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SAINT JOSEPH MERCY LIVINGSTON 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: | 620 BYRON RD | ||||||||
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| City: | HOWELL | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488431002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5175456000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2007 | ||||||||
| LastUpdateDate: | 12/14/2010 | ||||||||
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| AuthorizedOfficialLastName: | FAJA | ||||||||
| AuthorizedOfficialFirstName: | GARRY | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT CEO | ||||||||
| AuthorizedOfficialTelephone: | 7347123791 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SAINT JOSEPH MERCY LIVINGSTON HOSPITAL | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207V00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207ZB0001X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Blood Banking & Transfusion Medicine | 207ZD0900X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Dermatopathology | 207ZI0100X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Immunopathology | 207ZP0102X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LX0001X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Obstetrics & Gynecology | 207ZP0105X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Clinical Pathology/Laboratory Medicine |
ID Information
| ID | Type | State | Issuer | Description | 220D748270 | 01 | MI | BS BCN PATHOLOGY | OTHER |