Healthcare Provider Details

I. General information

NPI: 1619467677
Provider Name (Legal Business Name): TIMOTHY GATES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2018
Last Update Date: 01/17/2020
Certification Date: 01/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16250 NORTHLAND DR STE 369
SOUTHFIELD MI
48075-5208
US

IV. Provider business mailing address

14415 WOODMONT AVE
DETROIT MI
48227-4710
US

V. Phone/Fax

Practice location:
  • Phone: 248-798-8433
  • Fax: 248-487-9410
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: TIMOTHY GATES
Title or Position: NURSE PRACTITIONER
Credential: FNP-BC
Phone: 248-842-3755