Healthcare Provider Details

I. General information

NPI: 1396864849
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: 05/05/2026
Certification Date: 05/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5301 E HURON RIVER DRIVE SURGERY, MEDICAL
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: 734-712-7202
  • Fax:
Mailing address:
  • Phone: 734-343-3922
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name: ARIANA GRACE RAYMOND
Title or Position: MANAGER PROVIDER ENROLLMENT
Credential:
Phone: 734-343-1466