Healthcare Provider Details

I. General information

NPI: 1659501559
Provider Name (Legal Business Name): ELLY LANDOLFI MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2009
Last Update Date: 07/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

468 CADIEUX RD
GROSSE POINTE MI
48230-1507
US

IV. Provider business mailing address

15455 LAKESIDE VILLAGE DR APT 103
CLINTON TWP MI
48038-3539
US

V. Phone/Fax

Practice location:
  • Phone: 313-473-1615
  • Fax:
Mailing address:
  • Phone: 248-701-5380
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number4301095115
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: