Organization
MICHIGAN STATE UNIVERSITY
Active
Organization subpart
No
Provider details
NPI number
Authorized official
LISA M RUCKER (PROVIDER ENROLLMENT MANAGER)
(517) 355-8462
Entity
Organization
Contact information
Practice address
804 CLINICAL CENTER, A114, EAST LANSING, MI 48824-1313
(517) 355-7648
(517) 432-1390
Mailing address
804 SERVICE RD # A109F, EAST LANSING, MI 48824-7015
(517) 884-2976
(517) 432-3928
Taxonomy
Speciality
Code
Description
License number
State
261QP2000X
Physical Therapy Clinic/Center
Primary
5501007513
MI
261QX0100X
Occupational Medicine Clinic/Center
5201001302
MI
Other
Enumeration date
11/02/2006
Last updated
04/05/2018
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