Provider Demographics
NPI:1407391147
Name:VAN BUREN URGENT CARE
Entity Type:Organization
Organization Name:VAN BUREN URGENT CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CMO
Authorized Official - Prefix:
Authorized Official - First Name:SAMEER
Authorized Official - Middle Name:
Authorized Official - Last Name:HURAIBI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:734-699-9888
Mailing Address - Street 1:1806 WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-5010
Mailing Address - Country:US
Mailing Address - Phone:313-999-0449
Mailing Address - Fax:
Practice Address - Street 1:11650 BELLEVILLE RD
Practice Address - Street 2:SUITE 101
Practice Address - City:BELLEVILLE
Practice Address - State:MI
Practice Address - Zip Code:48111-3380
Practice Address - Country:US
Practice Address - Phone:734-699-9888
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-05
Last Update Date:2017-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704251692363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1538497250Medicaid
MI1538497250Medicaid