Healthcare Provider Details

I. General information

NPI: 1306059811
Provider Name (Legal Business Name): SAINT JOSEPH MERCY LIVINGSTON HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2007
Last Update Date: 01/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 GENOA BUSINESS PARK DR SUITE 180
BRIGHTON MI
48114-7367
US

IV. Provider business mailing address

34505 W 12 MILE RD SUITE 200
FARMINGTON HILLS MI
48331-3258
US

V. Phone/Fax

Practice location:
  • Phone: 810-844-7300
  • Fax:
Mailing address:
  • Phone: 734-343-3923
  • 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 GUSHO
Title or Position: SE MI REGIONAL C.F.O.
Credential:
Phone: 734-398-0642