Provider Demographics
NPI:1205081114
Name:ST MARYS OF MICHIGAN SPECIALISTS
Entity type:Organization
Organization Name:ST MARYS OF MICHIGAN SPECIALISTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP OF AMBULATORY SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:L
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:989-497-3095
Mailing Address - Street 1:4677 TOWNE CTR
Mailing Address - Street 2:MEDICAL ARTS 3 SUITE 201
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48604-2846
Mailing Address - Country:US
Mailing Address - Phone:989-497-3123
Mailing Address - Fax:989-497-3116
Practice Address - Street 1:4677 TOWNE CTR
Practice Address - Street 2:MEDICAL ARTS 3 SUITE 201
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48604-2846
Practice Address - Country:US
Practice Address - Phone:989-497-3123
Practice Address - Fax:989-497-3116
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST MARYSOF MICHIGAN SPECIALISTS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-11-19
Last Update Date:2008-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2082S0105XAllopathic & Osteopathic PhysiciansPlastic SurgerySurgery of the HandGroup - Multi-Specialty