Healthcare Provider Details

I. General information

NPI: 1053684647
Provider Name (Legal Business Name): ASCENSION PROVIDENCE HOSPTIAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/14/2012
Last Update Date: 06/28/2022
Certification Date: 06/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10415 GRAND RIVER RD 100
BRIGHTON MI
48116-6533
US

IV. Provider business mailing address

28000 DEQUINDRE RD
WARREN MI
48092-2468
US

V. Phone/Fax

Practice location:
  • Phone: 810-227-1020
  • Fax:
Mailing address:
  • Phone: 248-680-8000
  • Fax: 248-292-3852

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number StateMI
# 4
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: SARAH STARKEL
Title or Position: CREDENTIALING COORDINATOR
Credential:
Phone: 248-680-8121