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	2084P0800X	Psychiatry Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	260C310800	OTHER	MI	BCBS GROUP NUMBER

General Provider Information

NPI Number	:	1811942436
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	:	517-364-7700
Fax Number	:	517-364-7701

Provider Business Practice Location Address
First Line	:	1210 W SAGINAW ST
Second Line	:	2 ND FLOOR
City	:	LANSING
State	:	MI
Zip	:	48915-1927
Country	:	US
Telephone Number	:	517-364-7700
Fax Number	:	517-364-7701

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

Provider Enumeration Date	:	05/23/2006
Last Update Date	:	03/27/2024

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