Healthcare Provider Details

I. General information

NPI: 1518046598
Provider Name (Legal Business Name): MICHIGAN STATE UNIVERSITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2006
Last Update Date: 04/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

804 CLINICAL CENTER A114
EAST LANSING MI
48824-1313
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 517-355-7648
  • Fax: 517-432-1390
Mailing address:
  • Phone: 517-884-2976
  • Fax: 517-432-3928

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number5501007513
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code261QX0100X
TaxonomyOccupational Medicine Clinic/Center
License Number5201001302
License Number StateMI

VIII. Authorized Official

Name: LISA M RUCKER
Title or Position: PROVIDER ENROLLMENT MANAGER
Credential:
Phone: 517-355-8462