Provider Demographics
NPI:1447606801
Name:CENTRAL MICHIGAN UNIVERSITY
Entity Type:Organization
Organization Name:CENTRAL MICHIGAN UNIVERSITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ATHLETIC DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:989-774-7657
Mailing Address - Street 1:CMU SPORTS MEDICINE
Mailing Address - Street 2:ROSE 100
Mailing Address - City:MT PLEASANT
Mailing Address - State:MI
Mailing Address - Zip Code:48859-0001
Mailing Address - Country:US
Mailing Address - Phone:989-774-2281
Mailing Address - Fax:989-774-1095
Practice Address - Street 1:CMU SPORTS MEDICINE
Practice Address - Street 2:ROSE 100
Practice Address - City:MT PLEASANT
Practice Address - State:MI
Practice Address - Zip Code:48859-0001
Practice Address - Country:US
Practice Address - Phone:989-774-2281
Practice Address - Fax:989-774-1095
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:1588897896
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-05-04
Last Update Date:2016-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101018472207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Multi-Specialty