Healthcare Provider Details

I. General information

NPI: 1750790234
Provider Name (Legal Business Name): GATEWAY DETROITEAST
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/08/2014
Last Update Date: 08/08/2014
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: 313-921-1660
Mailing address:
  • Phone: 313-921-4700
  • Fax: 313-921-1660

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number6803084997
License Number StateMI

VIII. Authorized Official

Name: MS. ELIZABETH CICHON
Title or Position: CLINICAL DIRETOR
Credential:
Phone: 313-921-4700