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General NPI Number Information
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NPI Number | 1669759668
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Entity Type | Organization
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Legal Business Name | GATEWAY-DETROIT EAST
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Dates
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Enumeration Date | 11/04/2011
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Last Update Date | 07/30/2015
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Provider Practice Location Address
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Address Line | 6309 MACK AVE
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City | DETROIT
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State | MI
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Zip | 48207-2302
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Country | US
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Telephone | 313-921-4700
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Fax |
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Provider Business Mailing Address
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Address Line | 6309 MACK AVE
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City | DETROIT
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State | MI
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Zip | 48207-2302
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Country | US
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Telephone | 313-921-4700
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Fax |
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Authorized Official
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Title or Position | GROUP HEAD
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Name | DR. RADWAN KHOURY
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Credential | PH.D
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Telephone | 313-331-3435
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State |
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