Provider Demographics
NPI:1669759668
Name:GATEWAY-DETROIT EAST
Entity type:Organization
Organization Name:GATEWAY-DETROIT EAST
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:GROUP HEAD
Authorized Official - Prefix:DR
Authorized Official - First Name:RADWAN
Authorized Official - Middle Name:
Authorized Official - Last Name:KHOURY
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:313-331-3435
Mailing Address - Street 1:6309 MACK AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48207-2302
Mailing Address - Country:US
Mailing Address - Phone:313-921-4700
Mailing Address - Fax:
Practice Address - Street 1:6309 MACK AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48207-2302
Practice Address - Country:US
Practice Address - Phone:313-921-4700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-04
Last Update Date:2015-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty