Healthcare Provider Details

I. General information

NPI: 1891747614
Provider Name (Legal Business Name): MICHIGAN STATE UNIVERSITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/17/2006
Last Update Date: 04/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

804 SERVICE RD # D100
EAST LANSING MI
48824-7015
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 517-353-5053
  • Fax: 517-432-4394
Mailing address:
  • Phone: 517-884-2975
  • Fax: 517-432-3928

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2085D0003X
TaxonomyDiagnostic Neuroimaging (Radiology) Physician
License Number4301023246
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2085N0904X
TaxonomyNuclear Radiology Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number4301040697
License Number StateMI
# 7
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State

VIII. Authorized Official

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