Basic Information
| Provider Information | |||||||||
| NPI: | 1992712053 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MICHIGAN STATE UNIVERSITY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4660 S HAGADORN RD | ||||||||
| Address2: | STE 400 | ||||||||
| City: | EAST LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488235353 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5173557648 | ||||||||
| FaxNumber: | 5174321319 | ||||||||
| Practice Location | |||||||||
| Address1: | 4660 S HAGADORN RD STE 400 | ||||||||
| Address2: | |||||||||
| City: | EAST LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488235353 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5173557648 | ||||||||
| FaxNumber: | 5174321319 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/02/2006 | ||||||||
| LastUpdateDate: | 04/05/2018 | ||||||||
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| AuthorizedOfficialLastName: | RUCKER | ||||||||
| AuthorizedOfficialFirstName: | LISA | ||||||||
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| AuthorizedOfficialTitleorPosition: | ENROLLMENT & PATIENT ACCTS MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 5178842976 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 235Z00000X | N | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 225200000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant | 225100000X | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 30675 | 01 | MI | BCBSM FACILITY PIN | OTHER |