Basic Information
| Provider Information | |||||||||
| NPI: | 1144382250 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SPARROW IONIA HOSPITAL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | SMG MUIR | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 13008 | ||||||||
| Address2: | |||||||||
| City: | LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 489013008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5173646200 | ||||||||
| FaxNumber: | 5173646208 | ||||||||
| Practice Location | |||||||||
| Address1: | 1044 HAYDEN ROAD | ||||||||
| Address2: | |||||||||
| City: | MUIR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48860 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9898552755 | ||||||||
| FaxNumber: | 9898552766 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/14/2006 | ||||||||
| LastUpdateDate: | 01/05/2015 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ROESER | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9898552766 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SPARROW IONIA HOSPITAL | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 261QR1300X | 1060000167 | MI | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | MI8193 | 01 | MI | MEDICARE PTAN | OTHER | 1144382250 | 05 | MI | MEDICAID | 0C40058 | 01 | MI | BCBS | OTHER |