Basic Information
| Provider Information | |||||||||
| NPI: | 1538497250 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | VAN BUREN URGENT CARE CENTER PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11650 BELLEVILLE RD | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | VAN BUREN TWP | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48111 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7346999888 | ||||||||
| FaxNumber: | 7342931774 | ||||||||
| Practice Location | |||||||||
| Address1: | 11650 BELLEVILLE RD | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | VAN BUREN TWP | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48111 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7346999888 | ||||||||
| FaxNumber: | 7342931774 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/19/2009 | ||||||||
| LastUpdateDate: | 12/09/2010 | ||||||||
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| AuthorizedOfficialLastName: | HURAIBI | ||||||||
| AuthorizedOfficialFirstName: | SAMEER | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER MEDICAL DIRECTOR PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 3135150024 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 4301085918 | MI | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 182933 | 01 | MI | GREAT LAKES | OTHER | 1538497250 | 05 | MI | MEDICAID | 080H258740 | 01 | MI | BCBS GROUP | OTHER | DQ6601 | 01 | MI | RAILROAD MEDICARE | OTHER |