Provider Demographics
NPI:1992170187
Name:FADI DELLY, MD PC
Entity type:Organization
Organization Name:FADI DELLY, MD PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:FADI
Authorized Official - Middle Name:
Authorized Official - Last Name:DELLY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-755-9499
Mailing Address - Street 1:2211 FORT ST
Mailing Address - Street 2:
Mailing Address - City:WYANDOTTE
Mailing Address - State:MI
Mailing Address - Zip Code:48192-4135
Mailing Address - Country:US
Mailing Address - Phone:734-357-0505
Mailing Address - Fax:734-357-0506
Practice Address - Street 1:2211 FORT ST
Practice Address - Street 2:
Practice Address - City:WYANDOTTE
Practice Address - State:MI
Practice Address - Zip Code:48192-4135
Practice Address - Country:US
Practice Address - Phone:734-357-0505
Practice Address - Fax:734-357-0506
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-14
Last Update Date:2019-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010949222084N0008X, 2084N0400X, 2084P2900X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty
No2084N0008XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeuromuscular MedicineGroup - Multi-Specialty
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty
No2084P2900XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPain MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIMI9567Medicare PIN