Healthcare Provider Details

I. General information

NPI: 1699858431
Provider Name (Legal Business Name): MICHIGAN STATE UNIVERSITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/23/2006
Last Update Date: 04/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4660 S HAGADORN RD STE 420
EAST LANSING MI
48823-5353
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 517-884-6100
  • Fax: 517-884-6233
Mailing address:
  • Phone: 517-884-2976
  • Fax: 517-432-3928

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: LISA RUCKER
Title or Position: ENROLLMENT & PATIENT ACCTS MANAGER
Credential:
Phone: 517-884-2976