=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679501936
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ST JOSEPH MERCY HOSPITAL-SMHC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/28/2006
-----------------------------------------------------
Last Update Date | 07/01/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 44405 WOODWARD AVE
-----------------------------------------------------
City | PONTIAC
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48341-5023
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-858-3000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 44405 WOODWARD AVE
-----------------------------------------------------
City | PONTIAC
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48341-5023
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-858-3000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CFO
-----------------------------------------------------
Name | MR. MICHAEL P GUSHO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 231-672-3886
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 273R00000X
-----------------------------------------------------
Taxonomy Name | Psychiatric Hospital Unit
-----------------------------------------------------
License Number | H047
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------