Provider Demographics
NPI:1821041013
Name:EDWARD W. SPARROW HOSPITAL ASSOCIATION
Entity Type:Organization
Organization Name:EDWARD W. SPARROW HOSPITAL ASSOCIATION
Other - Org Name:UNIVERSITY OF MICHIGAN HEALTH-SPARROW DEWITT 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:517-669-9109
Mailing Address - Fax:517-669-9839
Practice Address - Street 1:13191 SCHAVEY RD
Practice Address - Street 2:SUITE 3
Practice Address - City:DEWITT
Practice Address - State:MI
Practice Address - Zip Code:48820-9036
Practice Address - Country:US
Practice Address - Phone:517-669-9109
Practice Address - Fax:517-669-9839
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SPARROW HEALTH SYSTEM
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-18
Last Update Date:2024-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI080A910070OtherBCBS GROUP NUMBER
MI0N17340Medicare PIN