Provider Demographics
NPI:1699870865
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:CHIEF MEDICAL OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:C
Authorized Official - Last Name:LESTER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:989-907-8345
Mailing Address - Street 1:4690 MCLEOD DR E
Mailing Address - Street 2:STE B
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:STE B
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:2006-09-13
Last Update Date:2008-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical CareGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P21660Medicare ID - Type UnspecifiedMCLEOD MEDICARE GRP #