Healthcare Provider Details

I. General information

NPI: 1043877053
Provider Name (Legal Business Name): ST MARY MERCY PHYSICIAN PRACTICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2019
Last Update Date: 05/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

37595 7 MILE RD STE 230
LIVONIA MI
48152-1003
US

IV. Provider business mailing address

44428 WOODWARD AVE STE 101
PONTIAC MI
48341-5009
US

V. Phone/Fax

Practice location:
  • Phone: 734-743-4540
  • Fax: 734-743-4541
Mailing address:
  • Phone: 248-858-3015
  • Fax: 248-858-6232

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: DAVID SPIVEY
Title or Position: PRESIDENT
Credential:
Phone: 734-655-1610