Basic Information
| Provider Information | |||||||||
| NPI: | 1790706901 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ST MARY MERCY HOSPITAL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 36475 5 MILE RD | ||||||||
| Address2: | |||||||||
| City: | LIVONIA | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481541971 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7346554800 | ||||||||
| FaxNumber: | 7346551274 | ||||||||
| Practice Location | |||||||||
| Address1: | 36475 5 MILE RD | ||||||||
| Address2: | |||||||||
| City: | LIVONIA | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481541971 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7346554800 | ||||||||
| FaxNumber: | 7346551274 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/22/2006 | ||||||||
| LastUpdateDate: | 05/03/2016 | ||||||||
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| AuthorizedOfficialLastName: | GUSHO | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | SEMI REGIONAL CFO | ||||||||
| AuthorizedOfficialTelephone: | 2488586174 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 820190 | MI | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 4200538 | 05 | MI | MEDICAID | 00243 | 01 | MI | BLUE CROSS ACUTE CARE | OTHER | 700H217250 | 01 | MI | BLUE SHIELD PHYSICIAN GRO | OTHER | 4200547 | 05 | MI | MEDICAID |