Provider Demographics
NPI:1255629358
Name:MICHIGAN STATE UNIVERSITY CLINICAL CENTER
Entity type:Organization
Organization Name:MICHIGAN STATE UNIVERSITY CLINICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MGR PROVIDER ENROLLMENT
Authorized Official - Prefix:
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:
Authorized Official - Last Name:ZALDOKAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:517-355-3503
Mailing Address - Street 1:804 SERVICE RD STE A114
Mailing Address - Street 2:
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48824-7038
Mailing Address - Country:US
Mailing Address - Phone:517-355-7648
Mailing Address - Fax:517-432-1319
Practice Address - Street 1:804 SERVICE RD STE A114
Practice Address - Street 2:
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48824-7038
Practice Address - Country:US
Practice Address - Phone:517-355-7648
Practice Address - Fax:517-432-1319
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-11
Last Update Date:2012-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301006498103T00000X
MI6301014684103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIC36082151Medicare PIN