Basic Information
| Provider Information | |||||||||
| NPI: | 1598145997 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EDWARD W. SPARROW HOSPITAL ASSOCIATION | ||||||||
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| OtherOrganizationName: | SPARROW SPORTS MEDICINE CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 13008 | ||||||||
| Address2: | |||||||||
| City: | LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 489013008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5173646200 | ||||||||
| FaxNumber: | 5173646208 | ||||||||
| Practice Location | |||||||||
| Address1: | 2900 HANNAH BLVD | ||||||||
| Address2: | SUITE B102 | ||||||||
| City: | EAST LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488235384 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5173648070 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2015 | ||||||||
| LastUpdateDate: | 06/02/2015 | ||||||||
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| AuthorizedOfficialLastName: | GALLUPS | ||||||||
| AuthorizedOfficialFirstName: | DIANE | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR, PROFESSIONAL BILLING SERV | ||||||||
| AuthorizedOfficialTelephone: | 5173646251 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RS0010X | 1060000091 | MI | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Sports Medicine |
No ID Information.