Basic Information
| Provider Information | |||||||||
| NPI: | 1396789798 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SPARROW CARSON HOSPITAL | ||||||||
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| OtherOrganizationName: | SPARROW MEDICAL GROUP PAIN MANAGEMENT CARSON CITY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. BOX 879 | ||||||||
| Address2: | 406 E. ELM STREET | ||||||||
| City: | CARSON CITY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488110879 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9895843971 | ||||||||
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| Practice Location | |||||||||
| Address1: | 406 E ELM ST | ||||||||
| Address2: | |||||||||
| City: | CARSON CITY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488119693 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9895843971 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2006 | ||||||||
| LastUpdateDate: | 06/18/2015 | ||||||||
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| AuthorizedOfficialLastName: | THOMPSON | ||||||||
| AuthorizedOfficialFirstName: | MATTHEW | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9895843971 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208VP0014X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine | 367500000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 207L00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 368419900 | 01 | MI | USDOL | OTHER | 050E910250 | 01 | MI | BCBS ANESTHESIOLOGISTS | OTHER | 430E910280 | 01 | MI | BCBS CRNAS | OTHER |