1992649750 NPI number — EAST DETROIT PRIMARY CARE, PLLC

Table of content: (NPI 1992649750)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992649750 NPI number — EAST DETROIT PRIMARY CARE, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EAST DETROIT PRIMARY CARE, PLLC
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:
1992649750
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/14/2026
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6455 GRATIOT AVE STE B
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DETROIT
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48207-1953
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
313-789-1800
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6455 GRATIOT AVE STE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DETROIT
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48207-1953
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
313-789-1800
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/14/2026

Additional Information

Authorized Official

Authorized Official Last Name:
JEFFRIES
Authorized Official First Name:
KETURAH
Authorized Official Middle Name:
Authorized Official Title or Position:
PHYSICIAN/OWNER
Authorized Official Telephone Number:
313-789-1800

Provider Taxonomy Codes

  • Taxonomy code: 207QH0002X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1780028829 . This is a "NPI TYPE 1" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".




Copyright © 2007-2026 www.npivalidator.com