Provider Demographics
NPI:1396847315
Name:STAR HEALTH MULTI-SPECIALTY GROUP PC
Entity Type:Organization
Organization Name:STAR HEALTH MULTI-SPECIALTY GROUP PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT CORPORATE OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:A
Authorized Official - Last Name:ROUSH
Authorized Official - Suffix:
Authorized Official - Credentials:RN BSN
Authorized Official - Phone:269-655-3000
Mailing Address - Street 1:PO BOX 489
Mailing Address - Street 2:451 HEALTH PARKWAY
Mailing Address - City:PAW PAW
Mailing Address - State:MI
Mailing Address - Zip Code:49079
Mailing Address - Country:US
Mailing Address - Phone:269-657-8300
Mailing Address - Fax:269-657-8332
Practice Address - Street 1:451 HEALTH PARKWAY
Practice Address - Street 2:
Practice Address - City:PAW PAW
Practice Address - State:MI
Practice Address - Zip Code:49079
Practice Address - Country:US
Practice Address - Phone:269-657-8300
Practice Address - Fax:269-657-8332
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OP30780Medicare ID - Type UnspecifiedGROUP