Healthcare Provider Details

I. General information

NPI: 1225237613
Provider Name (Legal Business Name): SPARROW EATON HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/16/2007
Last Update Date: 04/08/2025
Certification Date: 04/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 LANSING ST STE 230
CHARLOTTE MI
48813-2400
US

IV. Provider business mailing address

8175 RELIABLE PKWY
CHICAGO IL
60686-0081
US

V. Phone/Fax

Practice location:
  • Phone: 175-435-1105
  • Fax: 517-543-9776
Mailing address:
  • Phone: 517-253-6320
  • Fax: 517-253-6321

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License Number
License Number State

VIII. Authorized Official

Name: MISTY GUNTER RUSSIAN
Title or Position: SUPERVISOR, PROVIDER ENROLLMENT
Credential:
Phone: 517-253-6308