1205213014 NPI number — EDWARD W. SPARROW HOSPITAL ASSOCIATION

Table of content: (NPI 1205213014)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205213014 NPI number — EDWARD W. SPARROW HOSPITAL ASSOCIATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EDWARD W. SPARROW HOSPITAL ASSOCIATION
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1205213014
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/26/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8175 RELIABLE PKWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60686-0081
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
517-364-6200
Provider Business Mailing Address Fax Number:
517-364-6208

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
716 N CLIPPERT ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LANSING
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48912-4733
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
517-253-4000
Provider Business Practice Location Address Fax Number:
517-253-4003
Provider Enumeration Date:
04/30/2015

Additional Information

Authorized Official

Authorized Official Last Name:
RUSSIAN
Authorized Official First Name:
MISTY
Authorized Official Middle Name:
GUNTER
Authorized Official Title or Position:
SUPERVISOR, PROVIDER ENROLLMENT
Authorized Official Telephone Number:
517-253-6308

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X , with the licence number:  1060000091 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1205213014 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0C30919 . This is a "BCBS" identifier . This identifiers is of the category "OTHER".




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