=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033569553
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ST JOSEPH MERCY HOSPITAL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/15/2016
-----------------------------------------------------
Last Update Date | 10/05/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 24 FRANK LLOYD WRIGHT DR
-----------------------------------------------------
City | ANN ARBOR
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48105-9484
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-930-4020
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 34505 W 12 MILE RD SUITE 200
-----------------------------------------------------
City | FARMINGTON HILLS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48331-3258
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-343-3922
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CFO SE MI REGION
-----------------------------------------------------
Name | MICHAEL P GUSHO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 248-858-6174
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------