MEDICARE: CENTRAL MICHIGAN 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	208600000X	Surgery Physician		MI

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	:	1790058386
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CENTRAL MICHIGAN UNIVERSITY

Provider Business Mailing Address
First Line	:	2981 HEALTH PKWY
Second Line	:	SUITE B
City	:	MOUNT PLEASANT
State	:	MI
Zip	:	48858-9347
Country	:	US
Telephone Number	:	989-772-6880
Fax Number	:	989-772-6817

Provider Business Practice Location Address
First Line	:	2981 HEALTH PKWY
Second Line	:	SUITE B
City	:	MOUNT PLEASANT
State	:	MI
Zip	:	48858-9347
Country	:	US
Telephone Number	:	989-772-6880
Fax Number	:	989-772-6817

Authorized Official
Title or Position	:	PROVIDER ENROLLMENT SPECIALIST
Name	:	MR. KELLY J GRONDA
Credential	:
Telephone Number	:	989-774-3334

Provider Enumeration Date	:	02/14/2012
Last Update Date	:	10/22/2014

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Directions to “CENTRAL MICHIGAN UNIVERSITY ” Practice Location

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