Basic Information
| Provider Information | |||||||||
| NPI: | 1669759668 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GATEWAY-DETROIT EAST | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | DETROIT EAST HEALTH SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6309 MACK AVE | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482072302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3139214700 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 6309 MACK AVE | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482072302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3139214700 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/04/2011 | ||||||||
| LastUpdateDate: | 07/30/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KHOURY | ||||||||
| AuthorizedOfficialFirstName: | RADWAN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | GROUP HEAD | ||||||||
| AuthorizedOfficialTelephone: | 3133313435 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | PH.D | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 1223G0001X | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | General Practice | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 251S00000X | Y | Agencies | Community/Behavioral Health |
No ID Information.