Healthcare Provider Details

I. General information

NPI: 1417076951
Provider Name (Legal Business Name): ST JOSEPH MERCY HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/28/2007
Last Update Date: 10/05/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5301E HURON RIVER DR PEDIATRICS DEPARTMENT
YPSILANTI MI
48197-1051
US

IV. Provider business mailing address

34505 W 12 MILE RD STE 200
FARMINGTON HILLS MI
48331-3286
US

V. Phone/Fax

Practice location:
  • Phone: 734-712-3325
  • Fax:
Mailing address:
  • Phone: 734-343-3922
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL P GUSHO
Title or Position: CFO SE MI REGION
Credential:
Phone: 248-858-6174