Provider Demographics
NPI:1467535211
Name:MICHIGAN STATE UNIVERSITY
Entity Type:Organization
Organization Name:MICHIGAN STATE UNIVERSITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER ENROLLMENT MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:M
Authorized Official - Last Name:RUCKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:517-355-8462
Mailing Address - Street 1:804 SERVICE RD
Mailing Address - Street 2:ROOM A201
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48824-7015
Mailing Address - Country:US
Mailing Address - Phone:517-884-2976
Mailing Address - Fax:517-432-3928
Practice Address - Street 1:1215 E MICHIGAN AVE
Practice Address - Street 2:SPARROW HOSPITAL - NEONATOLOGY UNIT
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48912-1811
Practice Address - Country:US
Practice Address - Phone:517-364-2670
Practice Address - Fax:517-364-3994
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-23
Last Update Date:2018-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3043440Medicaid
MI3043440Medicaid