Provider Demographics
NPI:1699725895
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:517-355-8462
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:517-267-2460
Mailing Address - Fax:517-884-8602
Practice Address - Street 1:4660 S HAGADORN RD STE 600
Practice Address - Street 2:
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823-5383
Practice Address - Country:US
Practice Address - Phone:517-267-2460
Practice Address - Fax:517-884-8602
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-11
Last Update Date:2019-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207RE0101X, 207RH0003X, 207RI0200X, 207V00000X, 207VE0102X, 208600000X, 2086S0102X, 2086S0127X
MI4301097695207Y00000X
MI43010775382086X0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Multi-Specialty
No207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Multi-Specialty
No207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No207VE0102XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyReproductive EndocrinologyGroup - Multi-Specialty
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Multi-Specialty
No2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical CareGroup - Multi-Specialty
No2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma SurgeryGroup - Multi-Specialty
No2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical OncologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0C31049Medicare PIN
MIN90010002Medicare PIN
MI0C36019Medicare PIN
MI0C36088Medicare UPIN
MI0C36092Medicare PIN
MI0N42800Medicare UPIN
MI0C36165Medicare PIN
MI0C36179Medicare PIN
MI0C36082Medicare PIN