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General NPI Number Information
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NPI Number | 1821493974
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Entity Type | Organization
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Legal Business Name | BOARD OF TRUSTEES OF MICHIGAN STATE UNIVERSITY
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Dates
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Enumeration Date | 10/31/2014
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Last Update Date | 12/13/2019
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Provider Practice Location Address
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Address Line | 1200 E MICHIGAN AVE STE 145
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City | LANSING
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State | MI
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Zip | 48912-1800
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Country | US
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Telephone | 517-364-5440
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Fax | 517-364-5409
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Provider Business Mailing Address
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Address Line | 804 SERVICE RD STE A109B
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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 | ENROLLMENT & PATIENT ACCTS SUPER
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Name | LISA M RUCKER
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Credential |
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Telephone | 517-355-8462
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207K00000X
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Taxonomy Name | Allergy & Immunology Physician
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License Number | 4301035591
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License Number State | MI
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Taxonomy #2
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Taxonomy Code | 207RH0003X
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Taxonomy Name | Hematology & Oncology Physician
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License Number | 4301021298
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License Number State | MI
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Taxonomy #3
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Taxonomy Code | 2080P0214X
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Taxonomy Name | Pediatric Pulmonology Physician
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License Number | 4301035591
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License Number State | MI
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Taxonomy #4
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Taxonomy Code | 2080P0207X
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Taxonomy Name | Pediatric Hematology & Oncology Physician
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License Number | 4301045225
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License Number State | MI
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