Provider Demographics
NPI:1659711760
Name:CENTRAL MICHIGAN UNIVERSITY
Entity Type:Organization
Organization Name:CENTRAL MICHIGAN UNIVERSITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:J
Authorized Official - Last Name:GRONDA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:989-583-7415
Mailing Address - Street 1:1201 SOUTH DR
Mailing Address - Street 2:STE. 341
Mailing Address - City:MT PLEASANT
Mailing Address - State:MI
Mailing Address - Zip Code:48858-3256
Mailing Address - Country:US
Mailing Address - Phone:989-779-5270
Mailing Address - Fax:989-779-5279
Practice Address - Street 1:1201 SOUTH DR
Practice Address - Street 2:STE. 341
Practice Address - City:MT PLEASANT
Practice Address - State:MI
Practice Address - Zip Code:48858-3256
Practice Address - Country:US
Practice Address - Phone:989-779-5270
Practice Address - Fax:989-779-5279
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-03
Last Update Date:2013-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty