Basic Information
| Provider Information | |||||||||
| NPI: | 1720233968 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ASCENSION MEDICAL GROUP MICHIGAN | ||||||||
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| OtherOrganizationName: | MACOMB SLEEP INSTITUTE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 28000 DEQUINDRE ROAD | ||||||||
| Address2: | REVENUE CYCLE DEPARTMENT | ||||||||
| City: | WARREN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480921161 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2486808000 | ||||||||
| FaxNumber: | 2482923852 | ||||||||
| Practice Location | |||||||||
| Address1: | 17900 23 MILE RD | ||||||||
| Address2: | SUITE 406 | ||||||||
| City: | MACOMB | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480441161 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5868689075 | ||||||||
| FaxNumber: | 5868689077 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/01/2008 | ||||||||
| LastUpdateDate: | 06/27/2022 | ||||||||
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| AuthorizedOfficialLastName: | STARKEL | ||||||||
| AuthorizedOfficialFirstName: | SARAH | ||||||||
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| AuthorizedOfficialTitleorPosition: | SUPERVISOR | ||||||||
| AuthorizedOfficialTelephone: | 2486808000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 06/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QS1200X | MI | Y | Ambulatory Health Care Facilities | Clinic/Center | Sleep Disorder Diagnostic |
ID Information
| ID | Type | State | Issuer | Description | 700E012740 | 01 | MI | BCBSM GROUP NUMBER | OTHER |