Basic Information
| Provider Information | |||||||||
| NPI: | 1366498107 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EDWARD W. SPARROW HOSPITAL ASSOCIATION | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SPARROW CRNA SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 13008 | ||||||||
| Address2: | |||||||||
| City: | LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 489013008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5173643350 | ||||||||
| FaxNumber: | 5173643943 | ||||||||
| Practice Location | |||||||||
| Address1: | 1215 E MICHIGAN AVE | ||||||||
| Address2: | |||||||||
| City: | LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 489121811 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5173643350 | ||||||||
| FaxNumber: | 5173643943 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2006 | ||||||||
| LastUpdateDate: | 06/05/2020 | ||||||||
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| AuthorizedOfficialLastName: | GALLUPS | ||||||||
| AuthorizedOfficialFirstName: | DIANE | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR, PROFESSIONAL BILLING SERV | ||||||||
| AuthorizedOfficialTelephone: | 5173646251 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/05/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 207L00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 430C361330 | 01 | MI | BCBS GROUP NUMBER | OTHER |