=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134729114
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ST JOSEPH MERCY HOSPITAL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/28/2020
-----------------------------------------------------
Last Update Date | 10/28/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5301 E HURON RIVER DR
-----------------------------------------------------
City | YPSILANTI
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48197-1051
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-712-3456
-----------------------------------------------------
Fax | 734-712-0013
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 20555 VICTOR PKWY
-----------------------------------------------------
City | LIVONIA
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48152-7031
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-712-3456
-----------------------------------------------------
Fax | 312-957-2834
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CFO
-----------------------------------------------------
Name | MICHAEL PAUL GUSHO
-----------------------------------------------------
Credential | CFO
-----------------------------------------------------
Telephone | 248-858-6174
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 282N00000X
-----------------------------------------------------
Taxonomy Name | General Acute Care Hospital
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------