Basic Information
| Provider Information | |||||||||
| NPI: | 1518046598 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MICHIGAN STATE UNIVERSITY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 804 SERVICE RD # A109F | ||||||||
| Address2: | |||||||||
| City: | EAST LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488247015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5178842976 | ||||||||
| FaxNumber: | 5174323928 | ||||||||
| Practice Location | |||||||||
| Address1: | 804 CLINICAL CENTER | ||||||||
| Address2: | A114 | ||||||||
| City: | EAST LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488241313 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5173557648 | ||||||||
| FaxNumber: | 5174321390 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2006 | ||||||||
| LastUpdateDate: | 04/05/2018 | ||||||||
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| AuthorizedOfficialLastName: | RUCKER | ||||||||
| AuthorizedOfficialFirstName: | LISA | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | PROVIDER ENROLLMENT MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 5173558462 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QX0100X | 5201001302 | MI | N | Ambulatory Health Care Facilities | Clinic/Center | Occupational Medicine | 261QP2000X | 5501007513 | MI | Y | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
No ID Information.