Provider Demographics
NPI:1205285335
Name:EDWARD W. SPARROW HOSPITAL ASSOCIATION
Entity type:Organization
Organization Name:EDWARD W. SPARROW HOSPITAL ASSOCIATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
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:517-364-6253
Mailing Address - Fax:
Practice Address - Street 1:301 WILLIAMSTON CENTER RD
Practice Address - Street 2:
Practice Address - City:WILLIAMSTON
Practice Address - State:MI
Practice Address - Zip Code:48895-8502
Practice Address - Country:US
Practice Address - Phone:517-253-5125
Practice Address - Fax:517-253-5126
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SPARROW HEALTH SYSTEM
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-06-09
Last Update Date:2024-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1060000091207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty