MEDICARE: EDWARD W SPARROW HOSPITAL ASSOCIATION

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1124654793
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EDWARD W SPARROW HOSPITAL ASSOCIATION

Provider Business Mailing Address
First Line	:	8175 RELIABLE PKWY
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60686-0081
Country	:	US
Telephone Number	:	517-253-6320
Fax Number	:	517-253-6321

Provider Business Practice Location Address
First Line	:	2900 HANNAH BLVD STE 104
Second Line	:
City	:	EAST LANSING
State	:	MI
Zip	:	48823-5380
Country	:	US
Telephone Number	:	517-364-8000
Fax Number	:	517-364-8001

Authorized Official
Title or Position	:	SUPERVISOR, PROVIDER ENROLLMENT
Name	:	MISTY GUNTER RUSSIAN
Credential	:
Telephone Number	:	517-253-6308

Provider Enumeration Date	:	03/16/2020
Last Update Date	:	03/27/2024

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