Basic Information
| Provider Information | |||||||||
| NPI: | 1770553547 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SPARROW CARSON HOSPITAL | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SPARROW MEDICAL GROUP ITHACA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 730 | ||||||||
| Address2: | 406 E ELM ST | ||||||||
| City: | CARSON CITY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48811 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9895843131 | ||||||||
| FaxNumber: | 9895846734 | ||||||||
| Practice Location | |||||||||
| Address1: | 114 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | ITHACA | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48847 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9898754166 | ||||||||
| FaxNumber: | 9898753600 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/25/2006 | ||||||||
| LastUpdateDate: | 06/18/2015 | ||||||||
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| AuthorizedOfficialLastName: | THOMPSON | ||||||||
| AuthorizedOfficialFirstName: | MATTHEW | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9895843971 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
No ID Information.