1295788404 NPI number — EDWARD W. SPARROW HOSPITAL ASSOCIATION

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295788404 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:
1295788404
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:
60686-3008
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
517-364-8686
Provider Business Mailing Address Fax Number:
517-364-8685

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2909 E GRAND RIVER AVE
Provider Second Line Business Practice Location Address:
SUITE 211
Provider Business Practice Location Address City Name:
LANSING
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48912-4300
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
517-364-8686
Provider Business Practice Location Address Fax Number:
517-364-8685
Provider Enumeration Date:
05/18/2006

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: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 080C361700 . This is a "BCBS GROUP NUMBER" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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