Healthcare Provider Details

I. General information

NPI: 1265177810
Provider Name (Legal Business Name): SPARROW CARSON HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/28/2022
Last Update Date: 04/05/2024
Certification Date: 04/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

411 W BROADWAY ST STE B
MOUNT PLEASANT MI
48858-2446
US

IV. Provider business mailing address

8175 RELIABLE PKWY
CHICAGO IL
60686-0081
US

V. Phone/Fax

Practice location:
  • Phone: 517-364-5682
  • Fax: 517-364-5683
Mailing address:
  • Phone: 517-253-6320
  • Fax: 517-364-6353

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VX0201X
TaxonomyGynecologic 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