Provider Demographics
NPI:1184707937
Name:BOARD OF TRUSTEES OF MICHIGAN STATE UNIVERSITY
Entity type:Organization
Organization Name:BOARD OF TRUSTEES OF MICHIGAN STATE UNIVERSITY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:LEAD ENROLLMENT COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:RELANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:PRICE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:517-884-2976
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 1:4660 S HAGADORN RD
Practice Address - Street 2:STE 500
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823-5353
Practice Address - Country:US
Practice Address - Phone:517-884-4554
Practice Address - Fax:517-884-4556
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-23
Last Update Date:2023-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5901002366213E00000X
MI5601003216363A00000X
207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P23290Medicare PIN