Healthcare Provider Details

I. General information

NPI: 1952337545
Provider Name (Legal Business Name): MICHIGAN STATE UNIVERSITY DEPT OF PSYCHIATRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/24/2006
Last Update Date: 10/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

909 FEE RD ROOM B119
EAST LANSING MI
48824-6549
US

IV. Provider business mailing address

804 SERVICE RD A201
EAST LANSING MI
48824-7015
US

V. Phone/Fax

Practice location:
  • Phone: 517-353-3070
  • Fax: 517-432-3603
Mailing address:
  • Phone: 517-884-2976
  • Fax: 517-432-3928

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: KAREN L. ROMIG
Title or Position: PROVIDER ENROLLMENT
Credential:
Phone: 517-884-2976