MEDICARE: EDWARD W. SPARROW HOSPITAL ASSOCIATION

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	080C311250	OTHER	MI	BCBS GROUP NUMBER

General Provider Information

NPI Number	:	1437102357
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EDWARD W. SPARROW HOSPITAL ASSOCIATION

Provider Business Mailing Address
First Line	:	8175 RELIABLE PKWY
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60686-0081
Country	:	US
Telephone Number	:	517-381-6880
Fax Number	:	517-381-6881

Provider Business Practice Location Address
First Line	:	1600 W GRAND RIVER AVE
Second Line	:	SUITE 4
City	:	OKEMOS
State	:	MI
Zip	:	48864-2394
Country	:	US
Telephone Number	:	517-381-6880
Fax Number	:	517-381-6881

Authorized Official
Title or Position	:	SUPERVISOR, PROVIDER ENROLLMENT
Name	:	MISTY GUNTER RUSSIAN
Credential	:
Telephone Number	:	517-253-6308

Provider Enumeration Date	:	05/19/2006
Last Update Date	:	03/27/2024

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Directions to “EDWARD W. SPARROW HOSPITAL ASSOCIATION ” Practice Location

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