Provider Demographics
NPI:1386998755
Name:ELITE SPINE AND MUSCULOSKELETAL CENTER PLLC
Entity type:Organization
Organization Name:ELITE SPINE AND MUSCULOSKELETAL CENTER PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:DEREK
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:LADO
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:616-325-1224
Mailing Address - Street 1:3351 EAGLE RUN DR NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525-7070
Mailing Address - Country:US
Mailing Address - Phone:616-325-1224
Mailing Address - Fax:888-972-8067
Practice Address - Street 1:3351 EAGLE RUN DR NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-7070
Practice Address - Country:US
Practice Address - Phone:616-325-1224
Practice Address - Fax:888-972-8067
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-06
Last Update Date:2023-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI51010146702081P2900X
208100000X, 2081P0010X, 2081P2900X, 2081S0010X, 332B00000X, 2081N0008X, 204R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081N0008XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationNeuromuscular MedicineGroup - Multi-Specialty
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Single Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No2081P0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPediatric Rehabilitation MedicineGroup - Multi-Specialty
No2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports MedicineGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
No204R00000XAllopathic & Osteopathic PhysiciansElectrodiagnostic MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI108652Medicare UPIN