=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275165052
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MSU HEALTH CARE INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/10/2020
-----------------------------------------------------
Last Update Date | 01/23/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 804 SERVICE RD STE D100
-----------------------------------------------------
City | EAST LANSING
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48824-7015
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 517-353-5053
-----------------------------------------------------
Fax | 517-432-4394
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 804 SERVICE RD STE A109B
-----------------------------------------------------
City | EAST LANSING
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48824-7015
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 517-353-5053
-----------------------------------------------------
Fax | 517-432-4394
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LEAD ENROLLMENT COORDINATOR
-----------------------------------------------------
Name | RELANDA PRICE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 517-884-2976
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085N0700X
-----------------------------------------------------
Taxonomy Name | Neuroradiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2085N0904X
-----------------------------------------------------
Taxonomy Name | Nuclear Radiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 2085P0229X
-----------------------------------------------------
Taxonomy Name | Pediatric Radiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 2085B0100X
-----------------------------------------------------
Taxonomy Name | Body Imaging Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 2085D0003X
-----------------------------------------------------
Taxonomy Name | Diagnostic Neuroimaging (Radiology) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #6
-----------------------------------------------------
Taxonomy Code | 2085R0204X
-----------------------------------------------------
Taxonomy Name | Vascular & Interventional Radiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #7
-----------------------------------------------------
Taxonomy Code | 2085U0001X
-----------------------------------------------------
Taxonomy Name | Diagnostic Ultrasound Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #8
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------