Provider Demographics
NPI:1780658443
Name:ST JOSEPH MERCY HOSPITAL
Entity Type:Organization
Organization Name:ST JOSEPH MERCY HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO SE MI REGION
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:P
Authorized Official - Last Name:GUSHO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-858-6174
Mailing Address - Street 1:34505 W 12 MILE RD STE 200
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48331-3286
Mailing Address - Country:US
Mailing Address - Phone:734-343-3922
Mailing Address - Fax:
Practice Address - Street 1:5301 HURON RIVER DRIVE
Practice Address - Street 2:
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48197-1051
Practice Address - Country:US
Practice Address - Phone:734-712-3456
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-17
Last Update Date:2017-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI810030207VM0101X
282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes282N00000XHospitalsGeneral Acute Care Hospital
No207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4480502OtherAETNA SPORTSNET
MI1557023Medicaid
MI00042OtherBLUE CROSS AND BCN
MI100019OtherCARE CHOICES
MI5172017Medicaid
MI00042OtherBLUE CROSS AND BCN