Healthcare Provider Details

I. General information

NPI: 1548957707
Provider Name (Legal Business Name): BLUE WATER URGENT CARE PORT HURON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/19/2023
Last Update Date: 04/19/2023
Certification Date: 04/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1612 10TH AVE
PORT HURON MI
48060-3303
US

IV. Provider business mailing address

1612 10TH AVE
PORT HURON MI
48060-3303
US

V. Phone/Fax

Practice location:
  • Phone: 810-660-0242
  • Fax:
Mailing address:
  • Phone: 810-660-0242
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. IBRAHIM DABAJA
Title or Position: PRESIDENT
Credential: PA-C, PH.D.
Phone: 810-660-0242