Provider Demographics
NPI:1790058386
Name:CENTRAL MICHIGAN UNIVERSITY
Entity Type:Organization
Organization Name:CENTRAL MICHIGAN UNIVERSITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER ENROLLMENT SPECIALIST
Authorized Official - Prefix:MR
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:J
Authorized Official - Last Name:GRONDA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:989-774-3334
Mailing Address - Street 1:2981 HEALTH PKWY
Mailing Address - Street 2:SUITE B
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:MI
Mailing Address - Zip Code:48858-9347
Mailing Address - Country:US
Mailing Address - Phone:989-772-6880
Mailing Address - Fax:989-772-6817
Practice Address - Street 1:2981 HEALTH PKWY
Practice Address - Street 2:SUITE B
Practice Address - City:MOUNT PLEASANT
Practice Address - State:MI
Practice Address - Zip Code:48858-9347
Practice Address - Country:US
Practice Address - Phone:989-772-6880
Practice Address - Fax:989-772-6817
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-14
Last Update Date:2014-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4337963Medicaid
MI4337963Medicaid
E85377Medicare UPIN