Basic Information
| Provider Information | |||||||||
| NPI: | 1750790234 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GATEWAY DETROITEAST | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6309 MACK AVE | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482072302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3139214700 | ||||||||
| FaxNumber: | 3139211660 | ||||||||
| Practice Location | |||||||||
| Address1: | 6309 MACK AVE | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482072302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3139214700 | ||||||||
| FaxNumber: | 3139211660 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/08/2014 | ||||||||
| LastUpdateDate: | 08/08/2014 | ||||||||
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| AuthorizedOfficialLastName: | CICHON | ||||||||
| AuthorizedOfficialFirstName: | ELIZABETH | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CLINICAL DIRETOR | ||||||||
| AuthorizedOfficialTelephone: | 3139214700 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 302R00000X | 6803084997 | MI | Y | Managed Care Organizations | Health Maintenance Organization |
No ID Information.