Basic Information
| Provider Information | |||||||||
| NPI: | 1669431292 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EDWARD W. SPARROW HOSPITAL ASSOCIATION | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SPARROW BEHAVIORAL HEALTH SERVICES | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. BOX 30480 | ||||||||
| Address2: | 1215 E. MICHIGAN AVENUE | ||||||||
| City: | LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 489097980 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5173646000 | ||||||||
| FaxNumber: | 5173646009 | ||||||||
| Practice Location | |||||||||
| Address1: | 1210 W. SAGINAW STREET | ||||||||
| Address2: | |||||||||
| City: | LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 489121999 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5173646000 | ||||||||
| FaxNumber: | 5173646009 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2006 | ||||||||
| LastUpdateDate: | 11/09/2016 | ||||||||
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| AuthorizedOfficialLastName: | REICHLE | ||||||||
| AuthorizedOfficialFirstName: | PAULA | ||||||||
| AuthorizedOfficialMiddleName: | M. | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 5173641000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273R00000X | PH-040/2005(2) | MI | Y | Hospital Units | Psychiatric Unit |
ID Information
| ID | Type | State | Issuer | Description | 200000000005 | 01 | MI | PHP FAMILY CARE | OTHER | 00025 | 01 | MI | BLUE CROSS/BCN | OTHER | 30-1557293 | 05 | MI | MEDICAID |