Provider Demographics
NPI:1912541889
Name:BROSSY-WATERWORKS PC
Entity Type:Organization
Organization Name:BROSSY-WATERWORKS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KELLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:BROSSY
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:313-216-0332
Mailing Address - Street 1:21031 MICHIGAN AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-2339
Mailing Address - Country:US
Mailing Address - Phone:313-216-0332
Mailing Address - Fax:313-216-0332
Practice Address - Street 1:21031 MICHIGAN AVE FL 2
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-2339
Practice Address - Country:US
Practice Address - Phone:313-216-0332
Practice Address - Fax:313-216-0332
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-04
Last Update Date:2019-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Multi-Specialty