Provider Demographics
NPI:1356524789
Name:GLADWIN FAMILY PRACTICE
Entity type:Organization
Organization Name:GLADWIN FAMILY PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HICHAM
Authorized Official - Middle Name:
Authorized Official - Last Name:CHURBAJI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:989-426-9399
Mailing Address - Street 1:3061 CHRISTY WAY
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48603-2267
Mailing Address - Country:US
Mailing Address - Phone:989-426-9399
Mailing Address - Fax:
Practice Address - Street 1:2137 W M 61
Practice Address - Street 2:
Practice Address - City:GLADWIN
Practice Address - State:MI
Practice Address - Zip Code:48624-8463
Practice Address - Country:US
Practice Address - Phone:989-426-9399
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-07
Last Update Date:2007-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MISW130169164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Single Specialty