Provider Demographics
NPI:1134355902
Name:GATEWAY OBGYN ASSOCIATES PLLC
Entity type:Organization
Organization Name:GATEWAY OBGYN ASSOCIATES PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:THEODORE
Authorized Official - Middle Name:KEVIN
Authorized Official - Last Name:GRAHAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:313-875-4200
Mailing Address - Street 1:2888 W GRAND BLVD
Mailing Address - Street 2:ST. 287
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202-2612
Mailing Address - Country:US
Mailing Address - Phone:313-875-4200
Mailing Address - Fax:
Practice Address - Street 1:2888 W GRAND BLVD
Practice Address - Street 2:ST. 287
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202-2612
Practice Address - Country:US
Practice Address - Phone:313-875-4200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-06
Last Update Date:2012-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301050455207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty