MEDICARE: MATTHEW DELOST OT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225XH1200X	Hand Occupational Therapist	5201011293	MI

General Provider Information

NPI Number	:	1568438380
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MATTHEW DELOST OT

Provider Business Mailing Address
First Line	:	4100 LAKE DR SE STE 305
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49546-8292
Country	:	US
Telephone Number	:	616-267-9200
Fax Number	:

Provider Business Practice Location Address
First Line	:	4100 LAKE DR SE STE 305
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49546-8292
Country	:	US
Telephone Number	:	616-267-9200
Fax Number	:	616-416-1002

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/23/2006
Last Update Date	:	06/21/2023

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