Healthcare Provider Details

I. General information

NPI: 1992170187
Provider Name (Legal Business Name): FADI DELLY, MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/14/2015
Last Update Date: 06/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2211 FORT ST
WYANDOTTE MI
48192-4135
US

IV. Provider business mailing address

2211 FORT ST
WYANDOTTE MI
48192-4135
US

V. Phone/Fax

Practice location:
  • Phone: 734-357-0505
  • Fax: 734-357-0506
Mailing address:
  • Phone: 734-357-0505
  • Fax: 734-357-0506

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0008X
TaxonomyNeuromuscular Medicine (Psychiatry & Neurology) Physician
License Number4301094922
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number4301094922
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code2084P2900X
TaxonomyPain Medicine (Psychiatry & Neurology) Physician
License Number4301094922
License Number StateMI
# 4
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number4301094922
License Number StateMI

VIII. Authorized Official

Name: MR. FADI DELLY
Title or Position: OWNER
Credential: M.D.
Phone: 248-755-9499