Organization
MICHIGAN STATE UNIVERSITY
Active
Organization subpart
No
Provider details
NPI number
Authorized official
LISA RUCKER (ENROLLMENT & PATIENT ACCTS MANAGER)
(517) 884-2976
Entity
Organization
Contact information
Practice address
4660 S HAGADORN RD STE 420, EAST LANSING, MI 48823-5353
(517) 884-6100
(517) 884-6233
Mailing address
804 SERVICE RD # A109F, EAST LANSING, MI 48824-7015
(517) 884-2976
(517) 432-3928
Taxonomy
Speciality
Code
Description
License number
State
207QS0010X
Sports Medicine (Family Medicine) Physician
—
—
207X00000X
Orthopaedic Surgery Physician
Primary
—
—
363A00000X
Physician Assistant
—
—
Other
Enumeration date
10/23/2006
Last updated
04/05/2018
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