Provider Demographics
NPI:1053684647
Name:ASCENSION PROVIDENCE HOSPTIAL
Entity Type:Organization
Organization Name:ASCENSION PROVIDENCE HOSPTIAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:SARAH
Authorized Official - Middle Name:
Authorized Official - Last Name:STARKEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-680-8121
Mailing Address - Street 1:28000 DEQUINDRE RD
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48092-2468
Mailing Address - Country:US
Mailing Address - Phone:248-680-8000
Mailing Address - Fax:248-292-3852
Practice Address - Street 1:10415 GRAND RIVER RD
Practice Address - Street 2:100
Practice Address - City:BRIGHTON
Practice Address - State:MI
Practice Address - Zip Code:48116-6533
Practice Address - Country:US
Practice Address - Phone:810-227-1020
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-14
Last Update Date:2022-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X, 207R00000X
MI207RE0101X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty