Provider Demographics
NPI:1144309642
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:ENROLLMENT & PT ACCTS SUPERVISOR
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:517-884-2976
Mailing Address - Street 1:804 SERVICE RD RM 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 1:463 E CIRCLE DR
Practice Address - Street 2:
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48824-7500
Practice Address - Country:US
Practice Address - Phone:517-355-8237
Practice Address - Fax:517-432-0457
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-03
Last Update Date:2021-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0C31522Medicare PIN