Provider Demographics
NPI:1265650667
Name:DEROSE, ELIZABETH MORROW (MD)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:MORROW
Last Name:DEROSE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:
Other - Last Name:KOWAL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:360 GRAND RIVER DR NE
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:MI
Mailing Address - Zip Code:49301-9597
Mailing Address - Country:US
Mailing Address - Phone:248-563-9508
Mailing Address - Fax:
Practice Address - Street 1:300 68TH ST SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49548-6927
Practice Address - Country:US
Practice Address - Phone:616-281-6372
Practice Address - Fax:616-281-6459
Is Sole Proprietor?:No
Enumeration Date:2007-04-23
Last Update Date:2023-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43011064102084P0804X, 2084P0800X
IN01070813A2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201092700Medicaid
IN815500005Medicare PIN
IN000000786256OtherANTHEM PROVIDER NUMBER