Provider Demographics
NPI:1730208778
Name:SAINT JOSEPH MERCY LIVINGSTON HOSPITAL
Entity type:Organization
Organization Name:SAINT JOSEPH MERCY LIVINGSTON HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT CEO
Authorized Official - Prefix:
Authorized Official - First Name:GARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:FAJA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:734-712-3791
Mailing Address - Street 1:5301 E HURON RIVER DR
Mailing Address - Street 2:PO BOX 993, MC 69504
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48197-1051
Mailing Address - Country:US
Mailing Address - Phone:734-712-3456
Mailing Address - Fax:
Practice Address - Street 1:620 BYRON RD
Practice Address - Street 2:
Practice Address - City:HOWELL
Practice Address - State:MI
Practice Address - Zip Code:48843-1002
Practice Address - Country:US
Practice Address - Phone:517-545-6000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SAINT JOSEPH MERCY LIVINGSTON HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-29
Last Update Date:2010-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0105XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology/Laboratory MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No207ZB0001XAllopathic & Osteopathic PhysiciansPathologyBlood Banking & Transfusion MedicineGroup - Multi-Specialty
No207ZD0900XAllopathic & Osteopathic PhysiciansPathologyDermatopathologyGroup - Multi-Specialty
No207ZI0100XAllopathic & Osteopathic PhysiciansPathologyImmunopathologyGroup - Multi-Specialty
No207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & GynecologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI220D748270OtherBS BCN PATHOLOGY
MI0M03540Medicare ID - Type UnspecifiedPATHOLOGY