Provider Demographics
NPI:1366448037
Name:EAST LANSING ORTHOPEDIC ASSOCIATION P C
Entity type:Organization
Organization Name:EAST LANSING ORTHOPEDIC ASSOCIATION P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:A
Authorized Official - Last Name:DETRISAC
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:517-394-3200
Mailing Address - Street 1:3394 E JOLLY RD
Mailing Address - Street 2:STE A
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48910-8595
Mailing Address - Country:US
Mailing Address - Phone:517-394-3200
Mailing Address - Fax:517-394-4250
Practice Address - Street 1:3394 E JOLLY RD
Practice Address - Street 2:STE A
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48910-8595
Practice Address - Country:US
Practice Address - Phone:517-394-3200
Practice Address - Fax:517-394-4250
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-27
Last Update Date:2018-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIG04755OtherGROUP BCN
MI20-0C3-1063-0OtherGROUP BC/BS
MI20-0C3-1063-0OtherGROUP BC/BS