Provider Demographics
NPI:1578942033
Name:GAMBRELL, MAURICE JR
Entity Type:Individual
Prefix:
First Name:MAURICE
Middle Name:
Last Name:GAMBRELL
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20055 SOUTHFIELD FWY
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48235-2278
Mailing Address - Country:US
Mailing Address - Phone:313-556-4031
Mailing Address - Fax:
Practice Address - Street 1:20055 SOUTHFIELD FWY
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48235-2278
Practice Address - Country:US
Practice Address - Phone:313-556-4031
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-29
Last Update Date:2015-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174400000X
MI253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No253Z00000XAgenciesIn Home Supportive CareGroup - Multi-Specialty