Basic Information
| Provider Information | |||||||||
| NPI: | 1912026964 | ||||||||
| 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: | 7575 GRAND RIVER RD | ||||||||
| Address2: | AMB SUR | ||||||||
| City: | BRIGHTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481149309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8108447511 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | FAJA | ||||||||
| AuthorizedOfficialFirstName: | GARRY | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT CEO | ||||||||
| AuthorizedOfficialTelephone: | 7347123791 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.