Healthcare Provider Details

I. General information

NPI: 1295801108
Provider Name (Legal Business Name): SPARROW IONIA HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/24/2006
Last Update Date: 03/11/2024
Certification Date: 03/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9751 E GRAND RIVER AVE
PORTLAND MI
48875-9774
US

IV. Provider business mailing address

8175 RELIABLE PKWY
CHICAGO IL
60686-0081
US

V. Phone/Fax

Practice location:
  • Phone: 517-647-6722
  • Fax: 517-647-6838
Mailing address:
  • Phone: 616-523-1400
  • Fax: 616-523-1429

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number238631
License Number StateMI

VIII. Authorized Official

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