Provider Demographics
NPI:1629033683
Name:ASCENSION PROVIDENCE HOSPITAL
Entity Type:Organization
Organization Name:ASCENSION PROVIDENCE HOSPITAL
Other - Org Name:PH CARDIOLOGY II/PROVIDENCE HOSPTIAL AND MEDICAL CENTERS INC
Other - Org Type:Other Name
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 1:3168 SOLUTIONS CENTER BOX 773168
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-0001
Mailing Address - Country:US
Mailing Address - Phone:248-680-8000
Mailing Address - Fax:
Practice Address - Street 1:16001 W 9 MILE RD
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-4818
Practice Address - Country:US
Practice Address - Phone:248-849-3306
Practice Address - Fax:248-849-8504
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-20
Last Update Date:2023-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI060360240OtherBCBSM PIN NUMBR
MI0F36024Medicare PIN