Healthcare Provider Details

I. General information

NPI: 1245737402
Provider Name (Legal Business Name): EDWARD W SPARROW HOSPITAL ASSOCIATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/12/2018
Last Update Date: 07/28/2025
Certification Date: 07/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1140 E MICHIGAN AVE STE 400
LANSING MI
48912
US

IV. Provider business mailing address

8175 RELIABLE PKWY
CHICAGO IL
60686-0081
US

V. Phone/Fax

Practice location:
  • Phone: 517-364-9650
  • Fax: 517-364-9605
Mailing address:
  • Phone: 517-253-6320
  • Fax: 517-253-6321

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM1200X
TaxonomyMagnetic Resonance Imaging (MRI) Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number1060000091
License Number StateMI

VIII. Authorized Official

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