Healthcare Provider Details

I. General information

NPI: 1699725895
Provider Name (Legal Business Name): MICHIGAN STATE UNIVERSITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2006
Last Update Date: 10/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4660 S HAGADORN RD STE 600
EAST LANSING MI
48823-5383
US

IV. Provider business mailing address

804 SERVICE RD STE A109B
EAST LANSING MI
48824-7015
US

V. Phone/Fax

Practice location:
  • Phone: 517-267-2460
  • Fax: 517-884-8602
Mailing address:
  • Phone: 517-267-2460
  • Fax: 517-884-8602

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code207VE0102X
TaxonomyReproductive Endocrinology Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number4301097695
License Number StateMI
# 7
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License Number
License Number State
# 9
Primary TaxonomyN
Taxonomy Code2086S0127X
TaxonomyTrauma Surgery Physician
License Number
License Number State
# 10
Primary TaxonomyN
Taxonomy Code2086X0206X
TaxonomySurgical Oncology Physician
License Number4301077538
License Number StateMI

VIII. Authorized Official

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