Healthcare Provider Details

I. General information

NPI: 1912541889
Provider Name (Legal Business Name): BROSSY-WATERWORKS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/04/2019
Last Update Date: 11/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21031 MICHIGAN AVE FL 2
DEARBORN MI
48124-2339
US

IV. Provider business mailing address

21031 MICHIGAN AVE FL 2
DEARBORN MI
48124-2339
US

V. Phone/Fax

Practice location:
  • Phone: 313-216-0332
  • Fax: 313-216-0332
Mailing address:
  • Phone: 313-216-0332
  • Fax: 313-216-0332

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: DR. KELLEY BROSSY
Title or Position: OWNER
Credential: DO
Phone: 313-216-0332