Provider Demographics
NPI:1588747075
Name:SPARROW IONIA HOSPITAL
Entity type:Organization
Organization Name:SPARROW IONIA HOSPITAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SUPERVISOR. PROVIDER ENROLLMENT
Authorized Official - Prefix:
Authorized Official - First Name:MISTY
Authorized Official - Middle Name:GUNTER
Authorized Official - Last Name:RUSSIAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:517-253-6308
Mailing Address - Street 1:8175 RELIABLE PKWY
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60686-0081
Mailing Address - Country:US
Mailing Address - Phone:517-364-6253
Mailing Address - Fax:517-364-6204
Practice Address - Street 1:3565 S STATE RD
Practice Address - Street 2:
Practice Address - City:IONIA
Practice Address - State:MI
Practice Address - Zip Code:48846-9416
Practice Address - Country:US
Practice Address - Phone:616-523-1400
Practice Address - Fax:616-523-1429
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SPARROW HEALTH SYSTEM
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-20
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207R00000X, 207RH0003X, 207P00000X
MIJP038199207X00000X
MIAJ076427208600000X
MIRH014682208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Single Specialty
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI700C46006OtherBCBS OF MI
MI1588747075Medicaid
MI700C46006OtherBCBS OF MI