NPIMap

Organization Active NPI

Spine and Extremity Institute of South Lyon, L.L.C.

  • Physical Therapist
  • South Lyon, MI
National Provider Identifier
1811209968
Registry record updated Jul 6, 2010
On this page

Key facts

NPPES NPI Registry
Primary specialty
Physical TherapistTaxonomy code 225100000X
License
5501010651 Issued in MI
Legal business name
SPINE AND EXTREMITY INSTITUTE OF SOUTH LYON, L.L.C.
Practice address
22180 Pontiac Trail
Suite E
South Lyon, MI 48178-9097
Phone
(248) 446-0155
Fax
(248) 446-0177
NPI assigned
Jul 6, 2010
Last updated
Jul 6, 2010By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jul 6, 2010

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mr. Matthew Alexander Brostrom, MPT, CERT. MDT
Title
Owner/Director of Physical Therapy
Phone
(248) 446-0155

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Physical Therapist 225100000X 5501010651 MI Primary

Addresses

Primary practice location

22180 Pontiac Trail
Suite E
South Lyon, MI 48178-9097

Mailing address

22180 Pontiac Trail
Suite E
South Lyon, MI 48178-9097
Phone (248) 446-0155

Other names 1

  • Brostrom Physical Therapy Other name

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MI

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20110105000023 MI Part B Supplier - Clinic/Group Practice 3476742651 Receives reassigned benefits from 10 practitioners
Practice locations: South Lyon, MI

National Provider Directory

National Provider Directory

Locations

22180 Pontiac Trl
South Lyon, MI 48178
Phone (248) 446-0155

22180 Pontiac Trl
Ste E
South Lyon, MI 48178
Phone (248) 446-0155

Practitioners & affiliated clinicians

Practitioners 24

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 24

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1278374400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1278374400000",
    "number": "1811209968",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "22180 PONTIAC TRAIL",
            "address_2": "SUITE E",
            "city": "SOUTH LYON",
            "state": "MI",
            "postal_code": "481789097",
            "telephone_number": "248-446-0155",
            "fax_number": "248-446-0177"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "22180 PONTIAC TRAIL",
            "address_2": "SUITE E",
            "city": "SOUTH LYON",
            "state": "MI",
            "postal_code": "481789097",
            "telephone_number": "248-446-0155",
            "fax_number": "248-446-0177"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SPINE AND EXTREMITY INSTITUTE OF SOUTH LYON, L.L.C.",
        "organizational_subpart": "NO",
        "enumeration_date": "2010-07-06",
        "last_updated": "2010-07-06",
        "status": "A",
        "authorized_official_last_name": "BROSTROM",
        "authorized_official_first_name": "MATTHEW",
        "authorized_official_middle_name": "ALEXANDER",
        "authorized_official_title_or_position": "OWNER/DIRECTOR OF PHYSICAL THERAPY",
        "authorized_official_telephone_number": "248-446-0155",
        "authorized_official_name_prefix": "Mr.",
        "authorized_official_credential": "MPT, CERT. MDT"
    },
    "taxonomies": [
        {
            "code": "225100000X",
            "taxonomy_group": "",
            "desc": "Physical Therapist",
            "state": "MI",
            "license": "5501010651",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Brostrom Physical Therapy",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

Other providers in South Lyon, MI

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 6, 2010; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.