Provider Demographics
NPI:1699858431
Name:MICHIGAN STATE UNIVERSITY
Entity Type:Organization
Organization Name:MICHIGAN STATE UNIVERSITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ENROLLMENT & PATIENT ACCTS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:RUCKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:517-884-2976
Mailing Address - Street 1:804 SERVICE RD # A109F
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:517-884-2976
Mailing Address - Fax:517-432-3928
Practice Address - Street 1:4660 S HAGADORN RD STE 420
Practice Address - Street 2:
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823-5353
Practice Address - Country:US
Practice Address - Phone:517-884-6100
Practice Address - Fax:517-884-6233
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-23
Last Update Date:2018-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0C36093Medicare PIN
MI0N60000Medicare PIN
MI0C36088Medicare PIN