Healthcare Provider Details

I. General information

NPI: 1114930997
Provider Name (Legal Business Name): ST. JOSEPH MERCY HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/14/2006
Last Update Date: 06/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5333 MCAULEY DR SUITE 4015
YPSILANTI MI
48197-1014
US

IV. Provider business mailing address

5333 MCAULEY DR SUITE 4015
YPSILANTI MI
48197-1014
US

V. Phone/Fax

Practice location:
  • Phone: 734-712-5733
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VX0201X
TaxonomyGynecologic Oncology Physician
License Number
License Number State

VIII. Authorized Official

Name: ROLLAND MAMBOURG
Title or Position: VICE PRESIDENT PHYSICIAN RELATIONS
Credential: M.D.
Phone: 734-712-7358