Provider Demographics
NPI:1205880333
Name:MICHIGAN STATE UNIVERSITY
Entity type:Organization
Organization Name:MICHIGAN STATE UNIVERSITY
Other - Org Name:
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:517-364-5440
Mailing Address - Fax:517-364-5409
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:48912-1837
Practice Address - Country:US
Practice Address - Phone:517-364-5440
Practice Address - Fax:517-364-5466
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-22
Last Update Date:2023-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103T00000X, 207SG0201X, 2080P0006X, 2080P0202X, 2080P0208X, 2080P0214X, 2080P0216X, 2080P0207X
MI4301050648208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0207XAllopathic & Osteopathic PhysiciansPediatricsPediatric Hematology-OncologyGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No207SG0201XAllopathic & Osteopathic PhysiciansMedical GeneticsClinical Genetics (M.D.)Group - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No2080P0006XAllopathic & Osteopathic PhysiciansPediatricsDevelopmental - Behavioral PediatricsGroup - Multi-Specialty
No2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric CardiologyGroup - Multi-Specialty
No2080P0208XAllopathic & Osteopathic PhysiciansPediatricsPediatric Infectious DiseasesGroup - Multi-Specialty
No2080P0214XAllopathic & Osteopathic PhysiciansPediatricsPediatric PulmonologyGroup - Multi-Specialty
No2080P0216XAllopathic & Osteopathic PhysiciansPediatricsPediatric RheumatologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0C31049Medicare PIN
MI0C36092Medicare PIN
MI0C34654Medicare PIN
MI0C36088Medicare PIN
MI0C36072Medicare PIN
MI0C36082Medicare PIN