Provider Demographics
NPI:1598145997
Name:EDWARD W. SPARROW HOSPITAL ASSOCIATION
Entity Type:Organization
Organization Name:EDWARD W. SPARROW HOSPITAL ASSOCIATION
Other - Org Name:SPARROW SPORTS MEDICINE CLINIC
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:517-364-6200
Mailing Address - Fax:517-364-6208
Practice Address - Street 1:2900 HANNAH BLVD
Practice Address - Street 2:SUITE B102
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823-5384
Practice Address - Country:US
Practice Address - Phone:517-364-8070
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SPARROW HEALTH SYSTEM
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-06-02
Last Update Date:2024-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1060000091207RS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RS0010XAllopathic & Osteopathic PhysiciansInternal MedicineSports MedicineGroup - Multi-Specialty