Provider Demographics
NPI:1225306392
Name:ST MARY MERCY PHYSICIAN PRACTICES
Entity Type:Organization
Organization Name:ST MARY MERCY PHYSICIAN PRACTICES
Other - Org Name:ST MARY MERCY ONCOLOGY PRACTICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT / CEO
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:SPIVEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:734-655-1610
Mailing Address - Street 1:20555 VICTOR PKWY
Mailing Address - Street 2:SE MI SHARED SERVICES W3D
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48152-7031
Mailing Address - Country:US
Mailing Address - Phone:734-343-0282
Mailing Address - Fax:248-380-4445
Practice Address - Street 1:14555 LEVAN RD
Practice Address - Street 2:SUITE 112
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48154-5083
Practice Address - Country:US
Practice Address - Phone:734-779-2123
Practice Address - Fax:734-779-2163
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST MARY MERCY PHYSICIAN PRACTICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-12-05
Last Update Date:2015-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QX0200XAmbulatory Health Care FacilitiesClinic/CenterOncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0H27566OtherBLUE SHIELD PIN
MI0H27566OtherBLUE SHIELD PIN