Provider Demographics
NPI:1225237613
Name:SPARROW EATON HOSPITAL
Entity Type:Organization
Organization Name:SPARROW EATON HOSPITAL
Other - Org Name:UNIVERSITY OF MICHIGAN HEALTH-SPARROW CHARLOTTE 111 PRIMARY CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SUPERVISOR, PROVIDER ENROLLMENT
Authorized Official - Prefix:
Authorized Official - First Name:MISTY
Authorized Official - Middle Name:GUNTER
Authorized Official - Last Name:RUSSIAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:517-253-6308
Mailing Address - Street 1:8175 RELIABLE PKWY
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60686-0081
Mailing Address - Country:US
Mailing Address - Phone:517-253-6320
Mailing Address - Fax:517-253-6321
Practice Address - Street 1:111 LANSING ST STE 230
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:MI
Practice Address - Zip Code:48813-2400
Practice Address - Country:US
Practice Address - Phone:175-435-1105
Practice Address - Fax:517-543-9776
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SPARROW HEALTH SYSTEM
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-07-16
Last Update Date:2024-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI230020207Q00000X
261QX0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No261QX0200XAmbulatory Health Care FacilitiesClinic/CenterOncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0B36007OtherBCN FAMILY PRACTICE GROUP
MI0M32520Medicare PIN
MI0B36007OtherBCN FAMILY PRACTICE GROUP