Provider Demographics
NPI:1801940093
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:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:L
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:VP
Authorized Official - Phone:989-907-3095
Mailing Address - Street 1:4690 MCLEOD DR E
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48604-2836
Mailing Address - Country:US
Mailing Address - Phone:989-249-5454
Mailing Address - Fax:989-249-5468
Practice Address - Street 1:4690 MCLEOD DR E
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48604-2836
Practice Address - Country:US
Practice Address - Phone:989-249-5454
Practice Address - Fax:989-249-5468
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-23
Last Update Date:2008-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
208600000X, 2086S0127X, 174400000X
MI4301073051207ZP0102X
MI4301087160207ZP0102X
MI43010724782085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma SurgeryGroup - Multi-Specialty
No207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Multi-Specialty
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
=========OtherTAX ID