Healthcare Provider Details

I. General information

NPI: 1851470744
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: 04/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

804 SERVICE RD STE A217
EAST LANSING MI
48824-7015
US

IV. Provider business mailing address

804 SERVICE RD # A109F
EAST LANSING MI
48824-7015
US

V. Phone/Fax

Practice location:
  • Phone: 517-353-8122
  • Fax: 517-432-3928
Mailing address:
  • Phone: 517-884-2976
  • Fax: 517-432-3928

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number State
# 9
Primary TaxonomyN
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License Number
License Number State
# 10
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 11
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. LISA M RUCKER
Title or Position: ENROLLMENT & PATIENT ACCTS MANAGER
Credential:
Phone: 517-355-8462