Healthcare Provider Details

I. General information

NPI: 1336353663
Provider Name (Legal Business Name): ST JOSEPH MERCY HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/09/2007
Last Update Date: 10/05/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2004 HOGBACK RD SUITE 16
ANN ARBOR MI
48105-9738
US

IV. Provider business mailing address

34505 W 12 MILE RD STE 200
FARMINGTON HILLS MI
48331-3286
US

V. Phone/Fax

Practice location:
  • Phone: 734-712-3456
  • Fax:
Mailing address:
  • Phone: 734-343-3922
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TP0016X
TaxonomyPrescribing (Medical) Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL P GUSHO
Title or Position: CFO SE MI REGION
Credential:
Phone: 248-858-6174