Provider Demographics
NPI:1669686119
Name:ELIYA, FADI (MD)
Entity Type:Individual
Prefix:
First Name:FADI
Middle Name:
Last Name:ELIYA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:20952 E 12 MILE RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48081-3200
Mailing Address - Country:US
Mailing Address - Phone:586-771-4820
Mailing Address - Fax:586-771-6620
Practice Address - Street 1:1 WILLIAM CARLS DR STE 210
Practice Address - Street 2:
Practice Address - City:COMMERCE TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48382-2201
Practice Address - Country:US
Practice Address - Phone:248-387-2733
Practice Address - Fax:248-387-2735
Is Sole Proprietor?:No
Enumeration Date:2007-05-10
Last Update Date:2018-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301083976208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MICB9133OtherMEDICARE RAILROAD
MI0E06273OtherBCBSM
MICB9133OtherMEDICARE RAILROAD
MI0219690001Medicare NSC