Healthcare Provider Details

I. General information

NPI: 1386998755
Provider Name (Legal Business Name): ELITE SPINE AND MUSCULOSKELETAL CENTER PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/06/2012
Last Update Date: 08/14/2023
Certification Date: 08/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3351 EAGLE RUN DR NE
GRAND RAPIDS MI
49525-7070
US

IV. Provider business mailing address

3351 EAGLE RUN DR NE
GRAND RAPIDS MI
49525-7070
US

V. Phone/Fax

Practice location:
  • Phone: 616-325-1224
  • Fax: 888-972-8067
Mailing address:
  • Phone: 616-325-1224
  • Fax: 888-972-8067

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number5101014670
License Number StateMI

VIII. Authorized Official

Name: DR. DEREK ANTHONY LADO
Title or Position: MEMBER
Credential: D.O.
Phone: 616-325-1224