Provider Demographics
NPI:1871655290
Name:ERIC DERUSHA, D.C., P.C.
Entity Type:Organization
Organization Name:ERIC DERUSHA, D.C., P.C.
Other - Org Name:PAINT CREEK CHIROPRACTIC CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:D
Authorized Official - Last Name:DERUSHA
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:248-601-4540
Mailing Address - Street 1:528 N MAIN ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:ROCHESTER
Mailing Address - State:MI
Mailing Address - Zip Code:48307-1457
Mailing Address - Country:US
Mailing Address - Phone:248-601-4540
Mailing Address - Fax:248-601-4542
Practice Address - Street 1:528 N MAIN ST
Practice Address - Street 2:SUITE A
Practice Address - City:ROCHESTER
Practice Address - State:MI
Practice Address - Zip Code:48307-1457
Practice Address - Country:US
Practice Address - Phone:248-601-4540
Practice Address - Fax:248-601-4542
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-14
Last Update Date:2013-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FMED007362111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0N89970Medicare PIN