MEDICARE: EAST LANSING ORTHOPEDIC ASSOCIATION P C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207X00000X	Orthopaedic Surgery Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	G04755	OTHER	MI	GROUP BCN
2	20-0C3-1063-0	OTHER	MI	GROUP BC/BS

General Provider Information

NPI Number	:	1366448037
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EAST LANSING ORTHOPEDIC ASSOCIATION P C

Provider Business Mailing Address
First Line	:	3394 E JOLLY RD
Second Line	:	STE A
City	:	LANSING
State	:	MI
Zip	:	48910-8595
Country	:	US
Telephone Number	:	517-394-3200
Fax Number	:	517-394-4250

Provider Business Practice Location Address
First Line	:	3394 E JOLLY RD
Second Line	:	STE A
City	:	LANSING
State	:	MI
Zip	:	48910-8595
Country	:	US
Telephone Number	:	517-394-3200
Fax Number	:	517-394-4250

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. DAVID A DETRISAC
Credential	:	MD
Telephone Number	:	517-394-3200

Provider Enumeration Date	:	06/27/2005
Last Update Date	:	12/13/2018

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