Healthcare Provider Details

I. General information

NPI: 1629802491
Provider Name (Legal Business Name): MADISON ELIZABETH DELMARLE MS, PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2024
Last Update Date: 12/09/2024
Certification Date: 12/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18181 OAKWOOD BLVD STE 207
DEARBORN MI
48124-5031
US

IV. Provider business mailing address

18181 OAKWOOD BLVD STE 207
DEARBORN MI
48124-5031
US

V. Phone/Fax

Practice location:
  • Phone: 313-551-3745
  • Fax: 313-551-3984
Mailing address:
  • Phone: 313-551-3745
  • Fax: 313-551-3984

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number5601012703
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: