=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033476767
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | FERAH ADIL DALALY M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/19/2012
-----------------------------------------------------
Last Update Date | 10/14/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 17900 23 MILE RD SUITE 303
-----------------------------------------------------
City | MACOMB
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48044-1161
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-868-9800
-----------------------------------------------------
Fax | 586-868-9801
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 17900 23 MILE RD SUITE 303
-----------------------------------------------------
City | MACOMB
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48044-1161
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-868-9800
-----------------------------------------------------
Fax | 586-868-9801
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 4301100595
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------