Provider Demographics
NPI:1821493974
Name:BOARD OF TRUSTEES OF MICHIGAN STATE UNIVERSITY
Entity Type:Organization
Organization Name:BOARD OF TRUSTEES OF MICHIGAN STATE UNIVERSITY
Other - Org Name:MSU CMDS CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:ENROLLMENT & PATIENT ACCTS SUPER
Authorized Official - Prefix:
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 STE A109B
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 1:1200 E MICHIGAN AVE
Practice Address - Street 2:STE 145
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48912-1800
Practice Address - Country:US
Practice Address - Phone:517-364-5440
Practice Address - Fax:517-364-5409
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-31
Last Update Date:2019-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301035591207K00000X, 2080P0214X
MI4301021298207RH0003X
MI43010452252080P0207X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0207XAllopathic & Osteopathic PhysiciansPediatricsPediatric Hematology-OncologyGroup - Multi-Specialty
No207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Multi-Specialty
No207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Multi-Specialty
No2080P0214XAllopathic & Osteopathic PhysiciansPediatricsPediatric PulmonologyGroup - Multi-Specialty