Provider Demographics
NPI:1841233574
Name:SAINT MARYS HOME INFUSION PROGRAM
Entity type:Organization
Organization Name:SAINT MARYS HOME INFUSION PROGRAM
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:REGIONAL CFO AND TREASURER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:GUSHO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-672-3886
Mailing Address - Street 1:360 DIVISION AVE SOUTH
Mailing Address - Street 2:STE 1D
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503
Mailing Address - Country:US
Mailing Address - Phone:616-685-1111
Mailing Address - Fax:616-685-1122
Practice Address - Street 1:360 DIVISION AVE S
Practice Address - Street 2:STE #1D
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-4501
Practice Address - Country:US
Practice Address - Phone:616-685-1111
Practice Address - Fax:616-685-1122
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-13
Last Update Date:2025-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336H0001X, 3336S0011X, 333600000X, 251E00000X, 251F00000X, 261QI0500X, 332B00000X
MI53010075443336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
No333600000XSuppliersPharmacy
No251E00000XAgenciesHome Health
No251F00000XAgenciesHome Infusion
No261QI0500XAmbulatory Health Care FacilitiesClinic/CenterInfusion Therapy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4440561Medicaid
2046108OtherPK
5184170001Medicare NSC