Provider Demographics
NPI:1629157979
Name:BOARD OF TRUSTEES OF MICHIGAN STATE UNIVERSITY
Entity Type:Organization
Organization Name:BOARD OF TRUSTEES OF MICHIGAN STATE UNIVERSITY
Other - Org Name:MICHIGAN STATE UNIVERSITY
Other - Org Type:Doing Business As
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 1:1355 BOGUE STREET
Mailing Address - Street 2:ROOM B123
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48824-6239
Mailing Address - Country:US
Mailing Address - Phone:517-353-2032
Mailing Address - Fax:517-432-3879
Practice Address - Street 1:1355 BOGUE STREET
Practice Address - Street 2:ROOM B123
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48824-6239
Practice Address - Country:US
Practice Address - Phone:517-353-2032
Practice Address - Fax:517-432-3879
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-06
Last Update Date:2019-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1881849Medicaid
MI1881849Medicaid