Basic Information
Provider Information | |||||||||
NPI: | 1174562649 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | EDWARD W. SPARROW HOSPITAL ASSOCIATION | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | SPARROW REGIONAL CANCER CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 13008 | ||||||||
Address2: |   | ||||||||
City: | LANSING | ||||||||
State: | MI | ||||||||
PostalCode: | 489013008 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5173642890 | ||||||||
FaxNumber: | 5173642886 | ||||||||
Practice Location | |||||||||
Address1: | 1215 E MICHIGAN AVE | ||||||||
Address2: |   | ||||||||
City: | LANSING | ||||||||
State: | MI | ||||||||
PostalCode: | 489121811 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5173642890 | ||||||||
FaxNumber: | 5173642886 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/06/2006 | ||||||||
LastUpdateDate: | 06/21/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | GALLUPS | ||||||||
AuthorizedOfficialFirstName: | DIANE | ||||||||
AuthorizedOfficialMiddleName: | S | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR, PROFESSIONAL BILLING | ||||||||
AuthorizedOfficialTelephone: | 5173646251 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | EDWARD W. SPARROW HOSPITAL ASSOCIATION | ||||||||
AuthorizedOfficialNamePrefix: | MS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VX0201X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecologic Oncology | 207RH0003X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
ID | Type | State | Issuer | Description | 700C311320 | 01 | MI | BCBS GROUP NUMBER | OTHER |