Basic Information
Provider Information | |||||||||
NPI: | 1023041852 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ASCENSION MEDICAL GROUP MICHIGAN | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 28000 DEQUINDRE ROAD | ||||||||
Address2: | REVENUE CYCLE DEPARTMENT | ||||||||
City: | WARREN | ||||||||
State: | MI | ||||||||
PostalCode: | 480921135 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2486808000 | ||||||||
FaxNumber: | 2482923852 | ||||||||
Practice Location | |||||||||
Address1: | 11900 E 12 MILE RD | ||||||||
Address2: | SUITE 110 | ||||||||
City: | WARREN | ||||||||
State: | MI | ||||||||
PostalCode: | 480933400 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5865827070 | ||||||||
FaxNumber: | 5865827066 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/07/2006 | ||||||||
LastUpdateDate: | 06/27/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | STARKEL | ||||||||
AuthorizedOfficialFirstName: | SARAH | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | SUPERVISOR | ||||||||
AuthorizedOfficialTelephone: | 2486808121 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/27/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XS0114X |   | MI | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Adult Reconstructive Orthopaedic Surgery | 207XS0117X |   | MI | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Orthopaedic Surgery of the Spine | 207XX0004X |   | MI | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Foot and Ankle Surgery | 207XX0005X |   | MI | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine | 207XX0801X |   | MI | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Orthopaedic Trauma | 207X00000X |   | MI | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   |
ID Information
ID | Type | State | Issuer | Description | 0E011770 | 01 | MI | BCBSM GROUP NUMBER | OTHER | CG1891 | 01 | MI | RAILROAD MEDICARE GROUP NUMBER | OTHER | CG3113 | 01 | MI | RAILROAD MEDICARE GROUP NUMBER | OTHER | CB2735 | 01 | MI | RAILROAD MEDICARE GROUP NUMBER | OTHER | CG1892 | 01 | MI | RAILROAD MEDICARE GROUP NUMBER | OTHER |