Healthcare Provider Details

I. General information

NPI: 1801940093
Provider Name (Legal Business Name): ST MARYS OF MICHIGAN SPECIALISTS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/23/2007
Last Update Date: 12/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4690 MCLEOD DR E
SAGINAW MI
48604-2836
US

IV. Provider business mailing address

4690 MCLEOD DR E
SAGINAW MI
48604-2836
US

V. Phone/Fax

Practice location:
  • Phone: 989-249-5454
  • Fax: 989-249-5468
Mailing address:
  • Phone: 989-249-5454
  • Fax: 989-249-5468

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number4301073051
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number4301087160
License Number StateMI
# 4
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number4301072478
License Number StateMI
# 5
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code2086S0127X
TaxonomyTrauma Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL L LONG
Title or Position: VICE PRESIDENT
Credential: VP
Phone: 989-907-3095