MEDICARE: DR. DAVID A DETRISAC MD

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	4301044478	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	200000001107	OTHER	MI	PHYSICIANS HEALTH PLAN
2	2003300791	OTHER	MI	BLUE CROSS/BLUE SHIELD
3	0330079	OTHER	MI	BLUECARE NETWORK
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1730185539
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DAVID A DETRISAC MD

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	:
Name	:
Credential	:
Telephone Number	:

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

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