=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467727420
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DOWNRIVER ENDOCRINOLOGY PLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/09/2012
-----------------------------------------------------
Last Update Date | 01/25/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 15125 NORTHLINE RD
-----------------------------------------------------
City | SOUTHGATE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48195-2409
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-407-2311
-----------------------------------------------------
Fax | 734-282-1969
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15125 NORTHLINE RD
-----------------------------------------------------
City | SOUTHGATE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48195-2409
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-282-3138
-----------------------------------------------------
Fax | 734-282-1969
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRACTICE MANAGER
-----------------------------------------------------
Name | NADIA KHOURY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 734-282-3138
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RE0101X
-----------------------------------------------------
Taxonomy Name | Endocrinology, Diabetes & Metabolism Physician
-----------------------------------------------------
License Number | 4301046311
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------