# BOARD OF TRUSTEES OF MICHIGAN STATE UNIVERSITY

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- **Entity:** Organization
- **Status:** Active
- **Other names:** MSU CMDS CLINIC
- **Organization subpart:** No

## Provider details

- **NPI number:** 1821493974
- **Authorized official:** LISA M RUCKER (ENROLLMENT & PATIENT ACCTS SUPER)
- **Authorized official phone:** (517) 355-8462

## Contact information

- **Practice address:** 1200 E MICHIGAN AVE, STE 145, LANSING, MI 48912-1800
- **Practice address phone:** (517) 364-5440
- **Practice address fax:** (517) 364-5409
- **Mailing address:** 804 SERVICE RD STE A109B, EAST LANSING, MI 48824-7015
- **Mailing address phone:** (517) 884-2976
- **Mailing address fax:** (517) 432-3928

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207K00000X | Allergy & Immunology Physician | 4301035591 | MI | — |
| 207RH0003X | Hematology & Oncology Physician | 4301021298 | MI | — |
| 2080P0207X | Pediatric Hematology & Oncology Physician | 4301045225 | MI | Yes |
| 2080P0214X | Pediatric Pulmonology Physician | 4301035591 | MI | — |

## Other

- **Enumeration date:** 10/31/2014
- **Last updated:** 12/13/2019