Provider Demographics
NPI:1356981724
Name:DERY, PAUL E
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:E
Last Name:DERY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2214 RUSSELL ST
Mailing Address - Street 2:
Mailing Address - City:GRAND BLANC
Mailing Address - State:MI
Mailing Address - Zip Code:48439-4218
Mailing Address - Country:US
Mailing Address - Phone:810-610-8896
Mailing Address - Fax:
Practice Address - Street 1:1225 E BIG BEAVER RD
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48083-1905
Practice Address - Country:US
Practice Address - Phone:248-524-8801
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-13
Last Update Date:2020-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator