Basic Information
Provider Information | |||||||||
NPI: | 1548433626 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ASCENSION MEDICAL GROUP MICHIGAN | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 28000 DEQUINDRE ROAD | ||||||||
Address2: | REVENUE CYCLE DEPARTMENT | ||||||||
City: | WARREN | ||||||||
State: | MI | ||||||||
PostalCode: | 480921136 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2486808000 | ||||||||
FaxNumber: | 2482923852 | ||||||||
Practice Location | |||||||||
Address1: | 4014 RIVER RD | ||||||||
Address2: | 3B | ||||||||
City: | EAST CHINA | ||||||||
State: | MI | ||||||||
PostalCode: | 480542916 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8103294779 | ||||||||
FaxNumber: | 8103297860 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/09/2008 | ||||||||
LastUpdateDate: | 06/27/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | STARKEL | ||||||||
AuthorizedOfficialFirstName: | SARAH | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | SUPERVISOR | ||||||||
AuthorizedOfficialTelephone: | 2486808121 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
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AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/27/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 51011604 | MI | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |   |
No ID Information.