Healthcare Provider Details

I. General information

NPI: 1396110797
Provider Name (Legal Business Name): EDWARD W. SPARROW HOSPITAL ASSOCIATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/10/2015
Last Update Date: 12/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1215 E MICHIGAN AVE 6 WEST
LANSING MI
48912-1811
US

IV. Provider business mailing address

PO BOX 13008
LANSING MI
48901-3008
US

V. Phone/Fax

Practice location:
  • Phone: 517-364-1000
  • Fax:
Mailing address:
  • Phone: 517-364-6000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1060000091
License Number StateMI

VIII. Authorized Official

Name: DIANE S. GALLUPS
Title or Position: DIRECTOR, PROFESSIONAL BILLING
Credential:
Phone: 517-364-6251