Basic Information
Provider Information | |||||||||
NPI: | 1326257148 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ASCENSION MEDICAL GROUP MICHIGAN | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | MRG MPN OBGYN | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 28000 DEQUINDRE ROAD | ||||||||
Address2: | REVENUE CYCLE DEPARTMENT | ||||||||
City: | WARREN | ||||||||
State: | MI | ||||||||
PostalCode: | 480924826 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2486808000 | ||||||||
FaxNumber: | 2482923852 | ||||||||
Practice Location | |||||||||
Address1: | 15990 W 9 MILE RD | ||||||||
Address2: |   | ||||||||
City: | SOUTHFIELD | ||||||||
State: | MI | ||||||||
PostalCode: | 480754826 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2488494229 | ||||||||
FaxNumber: | 2488494240 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/21/2007 | ||||||||
LastUpdateDate: | 06/27/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | STARKEL | ||||||||
AuthorizedOfficialFirstName: | SARAH | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | SUPERVISOR | ||||||||
AuthorizedOfficialTelephone: | 2486808121 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/27/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VX0000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Obstetrics | 207VG0400X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecology |
No ID Information.