Healthcare Provider Details

I. General information

NPI: 1669759668
Provider Name (Legal Business Name): GATEWAY-DETROIT EAST
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/04/2011
Last Update Date: 07/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6309 MACK AVE
DETROIT MI
48207-2302
US

IV. Provider business mailing address

6309 MACK AVE
DETROIT MI
48207-2302
US

V. Phone/Fax

Practice location:
  • Phone: 313-921-4700
  • Fax:
Mailing address:
  • Phone: 313-921-4700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: DR. RADWAN KHOURY
Title or Position: GROUP HEAD
Credential: PH.D
Phone: 313-331-3435