Healthcare Provider Details

I. General information

NPI: 1447606801
Provider Name (Legal Business Name): CENTRAL MICHIGAN UNIVERSITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2016
Last Update Date: 05/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CMU SPORTS MEDICINE ROSE 100
MT PLEASANT MI
48859-0001
US

IV. Provider business mailing address

CMU SPORTS MEDICINE ROSE 100
MT PLEASANT MI
48859-0001
US

V. Phone/Fax

Practice location:
  • Phone: 989-774-2281
  • Fax: 989-774-1095
Mailing address:
  • Phone: 989-774-2281
  • Fax: 989-774-1095

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number5101018472
License Number StateMI

VIII. Authorized Official

Name: MATTHEW JACKSON
Title or Position: ATHLETIC DIRECTOR
Credential:
Phone: 989-774-7657