Provider Demographics
NPI:1477135036
Name:BLUE WATER URGENT CARE PLLC
Entity type:Organization
Organization Name:BLUE WATER URGENT CARE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:IBRAHIM
Authorized Official - Middle Name:
Authorized Official - Last Name:DABAJA
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C , PHD
Authorized Official - Phone:313-377-5758
Mailing Address - Street 1:3941 24TH AVE
Mailing Address - Street 2:
Mailing Address - City:FORT GRATIOT
Mailing Address - State:MI
Mailing Address - Zip Code:48059-4102
Mailing Address - Country:US
Mailing Address - Phone:810-882-9373
Mailing Address - Fax:
Practice Address - Street 1:3941 24TH AVE
Practice Address - Street 2:
Practice Address - City:FORT GRATIOT
Practice Address - State:MI
Practice Address - Zip Code:48059-4102
Practice Address - Country:US
Practice Address - Phone:810-882-9373
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-23
Last Update Date:2021-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care