Healthcare Provider Details

I. General information

NPI: 1104137967
Provider Name (Legal Business Name): FADI H DELLY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/27/2010
Last Update Date: 12/28/2020
Certification Date: 12/28/2020
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 Code2084N0400X
TaxonomyNeurology Physician
License Number4301094922
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number4301094922
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: