Provider Demographics
NPI:1467655886
Name:FONGER, EVAN BRADLEY (MD)
Entity Type:Individual
Prefix:DR
First Name:EVAN
Middle Name:BRADLEY
Last Name:FONGER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 MACK AVENUE
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201
Mailing Address - Country:US
Mailing Address - Phone:313-578-5000
Mailing Address - Fax:313-578-6379
Practice Address - Street 1:400 MACK AVENUE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201
Practice Address - Country:US
Practice Address - Phone:313-578-5000
Practice Address - Fax:313-578-6379
Is Sole Proprietor?:No
Enumeration Date:2007-06-06
Last Update Date:2019-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301087817207QH0002X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QH0002XAllopathic & Osteopathic PhysiciansFamily MedicineHospice and Palliative Medicine