Basic Information
| Provider Information | |||||||||
| NPI: | 1588737266 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ASCENSION MEDICAL GROUP MICHIGAN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 28000 DEQUINDRE ROAD | ||||||||
| Address2: | REVENUE CYCLE DEPARTMENT | ||||||||
| City: | WARREN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480921135 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2486808000 | ||||||||
| FaxNumber: | 2482923852 | ||||||||
| Practice Location | |||||||||
| Address1: | 46591 ROMEO PLANK RD | ||||||||
| Address2: | SUITE 205 | ||||||||
| City: | MACOMB | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480445742 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5862266250 | ||||||||
| FaxNumber: | 5862266204 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/17/2006 | ||||||||
| LastUpdateDate: | 06/27/2022 | ||||||||
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| AuthorizedOfficialLastName: | STARKEL | ||||||||
| AuthorizedOfficialFirstName: | SARAH | ||||||||
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| AuthorizedOfficialTitleorPosition: | SUPERVISOR | ||||||||
| AuthorizedOfficialTelephone: | 2486808121 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 06/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080A0000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Adolescent Medicine | 208000000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | CG3113 | 01 | MI | RAILROAD MEDICARE GROUP NUMBER | OTHER | 0E01172 | 01 | MI | BCBSM GROUP NUMBER | OTHER |