MEDICARE: FADI DELLY, MD PC

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	2084N0008X	Neuromuscular Medicine (Psychiatry & Neurology) Physician	4301094922	MI
2	2084N0400X	Neurology Physician	4301094922	MI
3	2084P2900X	Pain Medicine (Psychiatry & Neurology) Physician	4301094922	MI
4	208VP0014X	Interventional Pain Medicine Physician	4301094922	MI

General Provider Information

NPI Number	:	1992170187
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FADI DELLY, MD PC

Provider Business Mailing Address
First Line	:	2211 FORT ST
Second Line	:
City	:	WYANDOTTE
State	:	MI
Zip	:	48192-4135
Country	:	US
Telephone Number	:	734-357-0505
Fax Number	:	734-357-0506

Provider Business Practice Location Address
First Line	:	2211 FORT ST
Second Line	:
City	:	WYANDOTTE
State	:	MI
Zip	:	48192-4135
Country	:	US
Telephone Number	:	734-357-0505
Fax Number	:	734-357-0506

Authorized Official
Title or Position	:	OWNER
Name	:	MR. FADI DELLY
Credential	:	M.D.
Telephone Number	:	248-755-9499

Provider Enumeration Date	:	12/14/2015
Last Update Date	:	06/13/2019

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