Healthcare Provider Details

I. General information

NPI: 1629033683
Provider Name (Legal Business Name): ASCENSION PROVIDENCE HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/20/2006
Last Update Date: 11/15/2023
Certification Date: 11/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16001 W 9 MILE RD
SOUTHFIELD MI
48075-4818
US

IV. Provider business mailing address

3168 SOLUTIONS CENTER BOX 773168
CHICAGO IL
60677-0001
US

V. Phone/Fax

Practice location:
  • Phone: 248-849-3306
  • Fax: 248-849-8504
Mailing address:
  • Phone: 248-680-8000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: SARAH STARKEL
Title or Position: CREDENTIALING COORDINATOR
Credential:
Phone: 248-680-8121