Healthcare Provider Details

I. General information

NPI: 1366448037
Provider Name (Legal Business Name): EAST LANSING ORTHOPEDIC ASSOCIATION P C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/27/2005
Last Update Date: 12/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3394 E JOLLY RD STE A
LANSING MI
48910-8595
US

IV. Provider business mailing address

3394 E JOLLY RD STE A
LANSING MI
48910-8595
US

V. Phone/Fax

Practice location:
  • Phone: 517-394-3200
  • Fax: 517-394-4250
Mailing address:
  • Phone: 517-394-3200
  • Fax: 517-394-4250

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. DAVID A DETRISAC
Title or Position: PRESIDENT
Credential: MD
Phone: 517-394-3200