Healthcare Provider Details

I. General information

NPI: 1184707937
Provider Name (Legal Business Name): BOARD OF TRUSTEES OF MICHIGAN STATE UNIVERSITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/23/2006
Last Update Date: 04/18/2023
Certification Date: 04/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4660 S HAGADORN RD STE 500
EAST LANSING MI
48823-5353
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 517-884-4554
  • Fax: 517-884-4556
Mailing address:
  • Phone: 517-884-2976
  • Fax: 517-432-3928

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number5901002366
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601003216
License Number StateMI

VIII. Authorized Official

Name: RELANDA PRICE
Title or Position: LEAD ENROLLMENT COORDINATOR
Credential:
Phone: 517-884-2976