MEDICARE: BOARD OF TRUSTEES OF MICHIGAN STATE UNIVERSITY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	291U00000X	Clinical Medical Laboratory

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1629157979
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BOARD OF TRUSTEES OF MICHIGAN STATE UNIVERSITY

Provider Business Mailing Address
First Line	:	1355 BOGUE STREET
Second Line	:	ROOM B123
City	:	EAST LANSING
State	:	MI
Zip	:	48824-6239
Country	:	US
Telephone Number	:	517-353-2032
Fax Number	:	517-432-3879

Provider Business Practice Location Address
First Line	:	1355 BOGUE STREET
Second Line	:	ROOM B123
City	:	EAST LANSING
State	:	MI
Zip	:	48824-6239
Country	:	US
Telephone Number	:	517-353-2032
Fax Number	:	517-432-3879

Authorized Official
Title or Position	:	PROVIDER ENROLLMENT MANAGER
Name	:	MRS. LISA M RUCKER
Credential	:
Telephone Number	:	517-355-8462

Provider Enumeration Date	:	11/06/2006
Last Update Date	:	04/11/2019

Similar Medicare Providers

1770963100 — JOSEPH JACHER MS
Practice Location Address:

1355 BOGUE ST RM B220
EAST LANSING, MI
48824-6239

Practice Phone: 517-432-3870
Practice Fax:

1164401709 — MRS. TAMMY MARIE SIMMONS MHS, PT
Practice Location Address:

6239 S EAST ST , A
INDIANAPOLIS, IN
46227-2090

Practice Phone: 317-791-9031
Practice Fax:

1710018783 — MRS. CASSANDRA ELIZABETH CRUTCHFIELD
Practice Location Address:

6239 S EAST ST STE I
INDIANAPOLIS, IN
46227-2088

Practice Phone: 317-270-0522
Practice Fax: 317-791-9001

1962536169 — PAULA FRAZIER
Practice Location Address:

6239 S EAST ST
INDIANAPOLIS, IN
46227-2090

Practice Phone: 317-791-9031
Practice Fax:

1447377809 — MELISSA HUBBARD PT
Practice Location Address:

6239 S EAST ST STE A
INDIANAPOLIS, IN
46227-2088

Practice Phone: 317-791-9031
Practice Fax: 317-791-9001

1679695381 — PEDIPLAY LLC
Practice Location Address:

6239 S EAST ST , SUITE A
INDIANAPOLIS, IN
46227-2090

Practice Phone: 317-791-9031
Practice Fax: 317-791-9001

Directions to “BOARD OF TRUSTEES OF MICHIGAN STATE UNIVERSITY ” Practice Location

Language	Start Address	Practice Location

These directions are for planning purposes only. You may find that construction projects, traffic, or other events may cause road conditions to differ from the map results.

Copyright © 2007-2026 (Powered by Swiss Vault Engine), all rights reserved. HIPAA liability, trademark, document use and software licensing rules apply. All registered trademarks, used in the content, are the property of their owners. Your interactions with this site are in accordance with our Terms of Use and Privacy Policy.