Healthcare Provider Details

I. General information

NPI: 1487154290
Provider Name (Legal Business Name): EDWARD W SPARROW HOSPITAL ASSOCIATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/19/2018
Last Update Date: 10/01/2025
Certification Date: 10/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 E MICHIGAN AVE STE 510
LANSING MI
48912-1899
US

IV. Provider business mailing address

8175 RELIABLE PKWY
CHICAGO IL
60686-0081
US

V. Phone/Fax

Practice location:
  • Phone: 517-484-1381
  • Fax: 517-484-3034
Mailing address:
  • Phone: 517-253-6320
  • Fax: 517-364-6208

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

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