Provider Demographics
NPI:1326121179
Name:MICHIGAN STATE UNIVERSITY
Entity Type:Organization
Organization Name:MICHIGAN STATE UNIVERSITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LEAD ENROLLMENT COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:RELANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:PRICE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:517-884-2976
Mailing Address - Street 1:804 SERVICE RD STE A109B
Mailing Address - Street 2:
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48824-7015
Mailing Address - Country:US
Mailing Address - Phone:517-349-6560
Mailing Address - Fax:517-349-5796
Practice Address - Street 1:1600 W GRAND RIVER AVE
Practice Address - Street 2:STE 2
Practice Address - City:OKEMOS
Practice Address - State:MI
Practice Address - Zip Code:48864-2394
Practice Address - Country:US
Practice Address - Phone:517-349-6560
Practice Address - Fax:517-348-5796
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-23
Last Update Date:2023-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103T00000X, 204D00000X, 207Q00000X, 207SG0201X, 208000000X, 2080P0208X, 208100000X, 2081P2900X, 208800000X, 2088P0231X
MI5101011076207SG0201X
MI5101019945207XP3100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMMGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207SG0201XAllopathic & Osteopathic PhysiciansMedical GeneticsClinical Genetics (M.D.)Group - Multi-Specialty
No207XP3100XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryPediatric Orthopaedic SurgeryGroup - Multi-Specialty
No2080P0208XAllopathic & Osteopathic PhysiciansPediatricsPediatric Infectious DiseasesGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Multi-Specialty
No208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Multi-Specialty
No2088P0231XAllopathic & Osteopathic PhysiciansUrologyPediatric UrologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0C36082Medicare PIN
MI0C36165Medicare PIN
MI0C36092Medicare PIN
MI0C31043Medicare UPIN
MI0C34654Medicare PIN
MI0C31049Medicare PIN
MI0C36088Medicare PIN