1205073285 NPI number — DOWNRIVER CLINIC PC

Table of content: (NPI 1205073285)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205073285 NPI number — DOWNRIVER CLINIC PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DOWNRIVER CLINIC PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1205073285
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/15/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8944 MACOMB ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GROSSE ILE
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48138-2089
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
734-675-0705
Provider Business Mailing Address Fax Number:
734-675-0747

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8944 MACOMB ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GROSSE ILE
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48138-2089
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
734-675-0705
Provider Business Practice Location Address Fax Number:
734-675-0747
Provider Enumeration Date:
01/14/2009

Additional Information

Authorized Official

Authorized Official Last Name:
KHALED
Authorized Official First Name:
MOUNIR
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER MEDICAL DIRECTOR PHYSICIAN
Authorized Official Telephone Number:
734-675-0705

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  4301091157 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1205073285 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 259686 . This is a "DEPT OF LABOR STATE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: DO7341 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 174382 . This is a "GREAT LAKES" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 614738100 . This is a "DEPT OF LABOR" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 110H242960 . This is a "BCBS GROUP" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 82028050 . This is a "PROCARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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