Basic Information
| Provider Information | |||||||||
| NPI: | 1245737402 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EDWARD W SPARROW HOSPITAL ASSOCIATION | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | SPARROW THORACIC AND CARDIOVASCULAR INSTITUTE | ||||||||
| 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: | 5172536320 | ||||||||
| FaxNumber: | 5172536321 | ||||||||
| Practice Location | |||||||||
| Address1: | 1140 E MICHIGAN AVE STE 400 | ||||||||
| Address2: | |||||||||
| City: | LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48912 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5173649650 | ||||||||
| FaxNumber: | 5173649605 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/12/2018 | ||||||||
| LastUpdateDate: | 09/17/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GALLUPS | ||||||||
| AuthorizedOfficialFirstName: | DIANE | ||||||||
| AuthorizedOfficialMiddleName: | SUE | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR, PROFESSIONAL BILLING SERV | ||||||||
| AuthorizedOfficialTelephone: | 5172536337 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 1060000091 | MI | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
No ID Information.