Healthcare Provider Details

I. General information

NPI: 1376508333
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: 06/28/2022
Certification Date: 06/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16001 W 9 MILE RD
SOUTHFIELD MI
48075-4818
US

IV. Provider business mailing address

2800 LIVERNOIS RD SUITE 500
TROY MI
48083-1215
US

V. Phone/Fax

Practice location:
  • Phone: 248-849-3000
  • Fax: 248-849-2244
Mailing address:
  • Phone: 248-680-8000
  • Fax: 248-680-8032

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name: SARAH STARKEL
Title or Position: SUPERVISOR, ENROLLMENT
Credential:
Phone: 248-680-8206