Healthcare Provider Details

I. General information

NPI: 1124063078
Provider Name (Legal Business Name): SAINT MARY'S HEALTH SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/17/2006
Last Update Date: 01/30/2023
Certification Date: 01/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 JEFFERSON AVE SE
GRAND RAPIDS MI
49503-4502
US

IV. Provider business mailing address

200 JEFFERSON AVE SE
GRAND RAPIDS MI
49503-4502
US

V. Phone/Fax

Practice location:
  • Phone: 616-732-8956
  • Fax:
Mailing address:
  • Phone: 616-685-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL GUSHO
Title or Position: CFO, TREASURER
Credential:
Phone: 734-398-0642