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
804 SERVICE RD # D100, EAST LANSING, MI 48824-7015
(517) 353-5053
(517) 432-4394
Mailing address
804 SERVICE RD RM A109F, EAST LANSING, MI 48824-7015
(517) 884-2975
(517) 432-3928
Taxonomy
Speciality
Code
Description
License number
State
2085B0100X
Body Imaging Physician
—
—
2085D0003X
Diagnostic Neuroimaging (Radiology) Physician
4301023246
MI
2085N0700X
Neuroradiology Physician
—
—
2085N0904X
Nuclear Radiology Physician
—
—
2085R0202X
Diagnostic Radiology Physician
Primary
—
—
2085R0204X
Vascular & Interventional Radiology Physician
4301040697
MI
2085R0204X
Vascular & Interventional Radiology Physician
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1891747614
—
MI
Enumeration date
05/17/2006
Last updated
04/05/2018
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