Healthcare Provider Details

I. General information

NPI: 1760561658
Provider Name (Legal Business Name): MICHIGAN STATE UNIVERSITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/03/2006
Last Update Date: 06/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

804 SERVICE RD STE A233
EAST LANSING MI
48824-7015
US

IV. Provider business mailing address

D128 WEST FEE HALL
EAST LANSING MI
48824-1315
US

V. Phone/Fax

Practice location:
  • Phone: 517-432-6144
  • Fax: 517-432-6150
Mailing address:
  • Phone: 517-355-3503
  • Fax: 517-432-1167

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204C00000X
TaxonomySports Medicine (Neuromusculoskeletal Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License Number
License Number State

VIII. Authorized Official

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