Provider Demographics
NPI:1063624757
Name:ASCENSION MEDICAL GROUP MICHIGAN
Entity type:Organization
Organization Name:ASCENSION MEDICAL GROUP MICHIGAN
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:SARAH
Authorized Official - Middle Name:
Authorized Official - Last Name:STARKEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-680-8121
Mailing Address - Street 1:PO BOX 14129
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-4032
Mailing Address - Country:US
Mailing Address - Phone:248-680-8000
Mailing Address - Fax:248-292-3852
Practice Address - Street 1:17900 23 MILE RD
Practice Address - Street 2:SUITE 401
Practice Address - City:MACOMB
Practice Address - State:MI
Practice Address - Zip Code:48044-1161
Practice Address - Country:US
Practice Address - Phone:586-868-9040
Practice Address - Fax:586-868-9013
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-04
Last Update Date:2023-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI104624166Medicaid
MI610863700OtherUSDP
MI30789OtherBCBSM ID NUMBER
MI30789OtherBCBSM ID NUMBER
MI236815Medicare PIN
MI=========054OtherTRICARE ID NUMBER