Healthcare Provider Details

I. General information

NPI: 1497874531
Provider Name (Legal Business Name): SAINT JOSEPH MERCY LIVINGSTON HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/28/2007
Last Update Date: 07/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7575 GRAND RIVER URG CARE
BRIGHTON MI
48114
US

IV. Provider business mailing address

5301 E HURON RIVER DR PO BOX 993, MC 69504
YPSILANTI MI
48197-1051
US

V. Phone/Fax

Practice location:
  • Phone: 810-844-7511
  • Fax:
Mailing address:
  • Phone: 734-712-3456
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name: GARRY FAJA
Title or Position: PRESIDENT CEO
Credential:
Phone: 734-712-3791