Healthcare Provider Details

I. General information

NPI: 1619071115
Provider Name (Legal Business Name): STACY SUZANNE BULL MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: STACY SUZANNE DUCKLOW MD

II. Dates (important events)

Enumeration Date: 09/13/2006
Last Update Date: 09/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

463 E CIRCLE DR
EAST LANSING MI
48824-7500
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 517-884-6502
  • Fax: 517-355-9265
Mailing address:
  • Phone: 517-884-2976
  • Fax: 517-432-3928

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number4301070974
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: