Healthcare Provider Details

I. General information

NPI: 1629307251
Provider Name (Legal Business Name): MICHIGAN STATE UNIVERSITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/10/2009
Last Update Date: 12/10/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

346 OLIN HEALTH CTR EAST CIRCLE DRIVE
EAST LANSING MI
48824-1037
US

IV. Provider business mailing address

346 OLIN HEALTH CTR EAST CIRCLE DRIVE
EAST LANSING MI
48824-1037
US

V. Phone/Fax

Practice location:
  • Phone: 517-353-9101
  • Fax: 517-355-0332
Mailing address:
  • Phone: 517-353-9101
  • Fax: 517-355-0332

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4301054986
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code2083P0500X
TaxonomyPreventive Medicine/Occupational Environmental Medicine Physician
License Number4301051230
License Number StateMI

VIII. Authorized Official

Name: ELIZABETH ALEXANDER
Title or Position: UNIVERSITY PHYSICIAN
Credential: M.D.
Phone: 517-353-9101