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General NPI Number Information
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NPI Number | 1619071115
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Entity Type | Individual
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Provider Name | STACY SUZANNE BULL MD
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Gender | Female
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Dates
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Enumeration Date | 09/13/2006
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Last Update Date | 09/07/2018
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Provider Practice Location Address
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Address Line | 463 E CIRCLE DR
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City | EAST LANSING
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State | MI
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Zip | 48824-7500
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Country | US
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Telephone | 517-884-6502
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Fax | 517-355-9265
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Provider Business Mailing Address
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Address Line | 804 SERVICE RD # A109F
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City | EAST LANSING
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State | MI
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Zip | 48824-7015
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Country | US
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Telephone | 517-884-2976
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Fax | 517-432-3928
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207QS0010X
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Taxonomy Name | Sports Medicine (Family Medicine) Physician
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License Number | 4301070974
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License Number State | MI
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