MEDICARE: BLUE WATER PRIMARY CARE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1013896638
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLUE WATER PRIMARY CARE

Provider Business Mailing Address
First Line	:	3953 24TH AVE
Second Line	:
City	:	FORT GRATIOT
State	:	MI
Zip	:	48059-4193
Country	:	US
Telephone Number	:	810-363-9337
Fax Number	:

Provider Business Practice Location Address
First Line	:	3953 24TH AVE
Second Line	:
City	:	FORT GRATIOT
State	:	MI
Zip	:	48059-4193
Country	:	US
Telephone Number	:	734-299-0712
Fax Number	:

Authorized Official
Title or Position	:	CHIEF OPERATING OFFICER
Name	:	DR. IBRAHIM DABAJA
Credential	:	PA-C, PH.D.
Telephone Number	:	810-363-9337

Provider Enumeration Date	:	08/28/2025
Last Update Date	:	01/28/2026

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Directions to “BLUE WATER PRIMARY CARE ” Practice Location

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