NPIMap

Organization Active NPI

Sparrow Ionia Hospital

Doing business as SMG Portland

  • Rural Health Clinic/Center
  • Portland, MI
National Provider Identifier
1295801108
Registry record updated Mar 11, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
License
238631 Issued in MI
Legal business name
SPARROW IONIA HOSPITAL
Doing business as
SMG Portland
University of Michigan Health-Sparrow Portland Primary Care
Practice address
9751 E Grand River Ave
Portland, MI 48875-9774
Phone
(517) 647-6722
Fax
(517) 647-6838
NPI assigned
Nov 24, 2006
Last updated
Mar 11, 2024By the provider in NPPES
Organization subpart
Yes
Parent organization
SPARROW HEALTH SYSTEMAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Mar 11, 2024

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Misty Gunter Russian
Title
Supervisor. Provider Enrollment
Phone
(517) 253-6308

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207Q00000X
Rural Health Clinic/Center 261QR1300X 238631 MI Primary

Addresses

Primary practice location

9751 E Grand River Ave
Portland, MI 48875-9774

Mailing address

8175 Reliable Pkwy
Chicago, IL 60686-0081
Phone (616) 523-1400

Other names 2

  • SMG PORTLAND Doing business as
  • University of Michigan Health-Sparrow Portland Primary Care Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MI2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20031230000664 MI Part B Supplier - Clinic/Group Practice 0042118887 Receives reassigned benefits from 366 practitioners
12 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Carson City, MI; Ionia, MI; Portland, MI; Saint Johns, MI
O20090219000238 MI Part A Provider - Rural Health Clinic 0042118887 Practice locations: Portland, MI

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1295801108. Details of each certification follow.

Rural health clinic certification: CCN 238631

Legal name
SPARROW IONIA HOSPITAL
Doing business as
UNIVERSITY OF MICHIGAN HEALTH-SPARROW PORTLAND PRIMARY CARE
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Nov 19, 2010
Last certification
Oct 3, 2024
Ownership / control type
2B
Organization structure
OtherNon-profit
Enrollment address
1850 Hyland Dr
Portland, MI 48875-8508
Related CCNs
231331

Facilities connected through Provider of Services related, parent or unit certification numbers.

Other NPIs with the same Medicare PAC ID 3

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Other NPIs on the same Medicare enrollment 9

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
23D0951665Um Health-Sparrow Portland Primary Care1850 Hyland Drive, Portland, MI 48875Certificate of waiverJul 27, 2027

National Provider Directory

National Provider Directory
Tax ID family
Ionia County Mem Hosp C11 organizations share this tax ID, including this one
Part of
Sparrow Health System

Other organizations with this tax ID 10

Organizations that report the same tax identification number in the National Provider Directory.

Member of 2

Organizations this organization is a member of, according to the National Provider Directory.

Ownership & related parties

All disclosed owners & managing parties 19

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Matthew D Wilcox Individual Corporate OfficerBoard Member Jul 1, 2025
Eric J Strucko Individual Corporate OfficerBoard Member / Treasurer Jul 1, 2025
Laura M Gibson Individual Corporate OfficerBoard Member Jul 1, 2025
Um Health Organization, Ann Arbor, MI Corporation, Non-profit, Owned by another organization or individual 5% Or Greater Indirect Ownership Interest Apr 1, 2023 100%
Regents of the University of Michigan Organization, Ann Arbor, MI Corporation, Non-profit 5% Or Greater Indirect Ownership Interest Apr 1, 2023 100%
Candace S Metcalf Individual Corporate OfficerBoard Member Jul 1, 2025
Harper T Wildern Individual Corporate OfficerBoard Member / Board Chair Jul 1, 2025
Margaret a Dimond Individual Corporate OfficerPresident, Um Health Regional Netwk Jan 1, 2024
W-2 Managing EmployeeAd; Jan 1, 2024
Misty Gunter Russian Individual W-2 Managing EmployeeAd; Jan 1, 2024
Daniel Balice Individual Corporate OfficerBoard Member Jul 1, 2025
Carol Priebe Wiles Individual Corporate OfficerBoard Member Jul 1, 2025
Sparrow Health System Organization, Lansing, MI Corporation, Non-profit, Owned by another organization or individual 5% Or Greater Direct Ownership Interest Dec 2, 2010 100%
John Milewski Individual Corporate OfficerBoard Member Jul 1, 2025
Gregory a Holzhei Individual Corporate OfficerBoard Member/ Secretary Jul 1, 2025
John Hendrickson Individual Corporate OfficerBoard Member/ Vice Chair Jul 1, 2025
Bruce a Courtade Individual Corporate OfficerBoard Member Jul 1, 2025
Anthony Mazzali Individual Corporate OfficerBoard Member Jul 1, 2025
Timothy L Williams Individual Corporate OfficerBoard Member Jul 1, 2025
Lakeeya K Tucker Individual Corporate OfficerBoard Member Jul 1, 2025

Owners & managing parties with NPI records 4

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

Facilities with the same owner 19

Facilities that share an organizational owner with 5% or greater ownership or operational control.

View all 19

Practitioners & affiliated clinicians

Practitioners 10

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1164326400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1710115200000",
    "number": "1295801108",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "8175 RELIABLE PKWY",
            "city": "CHICAGO",
            "state": "IL",
            "postal_code": "606860081",
            "telephone_number": "616-523-1400",
            "fax_number": "616-523-1429"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "9751 E GRAND RIVER AVE",
            "city": "PORTLAND",
            "state": "MI",
            "postal_code": "488759774",
            "telephone_number": "517-647-6722",
            "fax_number": "517-647-6838"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SPARROW IONIA HOSPITAL",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "SPARROW HEALTH SYSTEM",
        "enumeration_date": "2006-11-24",
        "last_updated": "2024-03-11",
        "certification_date": "2024-03-11",
        "status": "A",
        "authorized_official_last_name": "RUSSIAN",
        "authorized_official_first_name": "MISTY",
        "authorized_official_middle_name": "GUNTER",
        "authorized_official_title_or_position": "SUPERVISOR. PROVIDER ENROLLMENT",
        "authorized_official_telephone_number": "517-253-6308"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": "MI",
            "license": "238631",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "SMG PORTLAND",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "University of Michigan Health-Sparrow Portland Primary Care",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Portland, MI

Sources for this page

Verify at the official NPI Registry.