Healthcare Provider Details

I. General information

NPI: 1205213014
Provider Name (Legal Business Name): EDWARD W. SPARROW HOSPITAL ASSOCIATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/30/2015
Last Update Date: 09/15/2025
Certification Date: 09/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2446 JOLLY RD STE B
OKEMOS MI
48864-3514
US

IV. Provider business mailing address

8175 RELIABLE PKWY
CHICAGO IL
60686-0081
US

V. Phone/Fax

Practice location:
  • Phone: 517-253-5530
  • Fax: 517-253-5535
Mailing address:
  • Phone: 517-364-6200
  • Fax: 517-364-6208

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number1060000091
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

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