Basic Information
| Provider Information | |||||||||
| NPI: | 1831508522 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GATEWAY DETROIT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11457 SHOEMAKER ST | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482133418 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3133313435 | ||||||||
| FaxNumber: | 3139240609 | ||||||||
| Practice Location | |||||||||
| Address1: | 11457 SHOEMAKER ST | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482133418 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3133313435 | ||||||||
| FaxNumber: | 3139240609 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/06/2014 | ||||||||
| LastUpdateDate: | 08/06/2014 | ||||||||
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| AuthorizedOfficialLastName: | CARR | ||||||||
| AuthorizedOfficialFirstName: | FREDERICK | ||||||||
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| AuthorizedOfficialTitleorPosition: | SOCIAL WORKER/CASE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 3133313435 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | GATEWAY | ||||||||
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| AuthorizedOfficialCredential: | B.S.,S.S.T | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 305R00000X | 6803086187 | MI | Y | Managed Care Organizations | Preferred Provider Organization |
No ID Information.