Provider Demographics
NPI:1194980524
Name:SPARROW MEDICAL GROUP
Entity type:Organization
Organization Name:SPARROW MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:MILDRED
Authorized Official - Middle Name:WARE
Authorized Official - Last Name:SCOTT
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:318-934-0082
Mailing Address - Street 1:PO BOX 7276
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71137-7276
Mailing Address - Country:US
Mailing Address - Phone:318-934-0082
Mailing Address - Fax:318-934-0087
Practice Address - Street 1:3736 N MARKET ST
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71107-3104
Practice Address - Country:US
Practice Address - Phone:318-934-0082
Practice Address - Fax:318-934-0087
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-24
Last Update Date:2008-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1167789Medicaid